1. Manual on Point Prevalence Survey
Transcript of 1. Manual on Point Prevalence Survey
1
Second Edition November 2013
HEALTHCARE ASSOCIATED INFECTION (HCAI) SURVEILLANCE
Quality in Medical Care Section Medical Development Division
Ministry of Health
Point Prevalence Survey
for
Healthcare Associated Infection
Surveillance
Manual
DRAFT
2
PAGE Abbreviations 3
Committee Members 4
Background 5
Objectives 6
Methodology a. Design b. Population under surveillance c. Definitions d. Calculation of Prevalence Rate e. Inclusion and Exclusion criteria f. Survey Instrument
6 6 7 9
10 11
Data Collection 12
Compilation of data and report 14
Algorithm for Healthcare Associated Infection Surveillance through PPS
16
APPENDIX 1: Definitions Of Healthcare Associated Infection
17
APPENDIX 2: Healthcare Associated Infection Surveillance Form (HCAI-PPS/MOH/2013/1)
33
APPENDIX 3: Healthcare Associated Infection Surveillance Reporting Form Section A (HCAI-PPS/MOH/2013/2)
36
APPENDIX 4: Healthcare Associated Infection Surveillance Reporting Form Section B (HCAI-PPS/MOH/2013/3)
38
APPENDIX 5: Line Listing For HCAI Surveillance - PPS
40
References 42
Contents
3
A&E Accident and emergency
AMR Antimicrobial resistance
BSI Bloodstream infection
CDC Centre for Disease Control and Prevention
CFU Colony-forming units
CVC Central vascular catheter
ESBL Extended-spectrum beta-lactamase
HCAI Healthcare-associated infections
ICN Infection control nurse
ICU Intensive care unit
MOH Ministry of Health
PPS Point Prevalence Survey
PVC Peripheral vascular catheter
SSI Surgical site infections
WHO World Health Organization
Abbreviations
4
Dr Zubaidah Abdul Wahab Senior Consultant Clinical Microbiologist Hospital Sungai Buloh, Selangor Dr Nurahan Maning Senior Consultant Clinical Microbiologist Hospital Raja Perempuan Zainab II, Kota Bharu Datin Dr R. Ganeswrie Senior Consultant Clinical Microbiologist Hospital Sutanah Aminah, Johor Bahru Dr Shahnaz Shah Firdaus Khan Senior Consultant Nephrologist Hospital Tengku Ampuan Rahimah, Klang Dato’ Dr Sapari Satwi Senior Consultant Physician (Infectious Disease) Hospital Tengku Ampuan Afzan, Kuantan Dr Kamarul Azahar Mohd Razali Senior Consultant Paediatrician (Infectious Disease) Hospital Kuala Lumpur Dr Ker Hong Bee Consultant Physician (Infectious Disease) Hospital Raja Permaisuri Bainun, Ipoh Dr Jamaludin Mohamad Consultant Paediatrician Hospital Tuanku Fauziah, Kangar Dr Tuan Suhaila Tuan Soh Clinical Microbiologist Hospital Sungai Buloh, Selangor
Dr Suraya Amir Husin Senior Principal Assistant Director Infection Control Unit Medical Development Division
Dr Suhaila Hanapiah Clinical Microbiologist National Cancer Institute, Putrajaya Dr Sahlawati Mustakim Clinical Microbiologist Hospital Tengku Ampuan Rahimah, Klang
Dr Anis Baidura Azal Senior Assistant Director Infection Control Unit Medical Development Division
Pn Hadijah Mohd Taib Pharmacist Hospital Kuala Lumpur Pn Saabah Rosnan Nursing Sister Infection Control Unit Medical Development Division Pn Zawiah Mamat@ Mohd Dris Nursing Sister Infection Control Unit Medical Development Division
Committee Members
5
The prevalence of hospital infections in Malaysia is being observed through the Healthcare
Associated Infections (HCAI) surveillance programme. The HCAI prevalence is determined
through a one-day hospital wide point prevalence survey (PPS) which is conducted twice a year
in March and September. The PPS started in 2003 involving 14 Ministry of Health (MOH) and 3
university hospitals. Currently the surveillance data from 20 MOH and 3 university hospitals is
analysed twice a year.
The HCAI are categorized into the common types of infection occurring in hospitals, which are
the urinary tract infections (UTI), pneumonia, surgical site infections (SSI), blood stream
infections (BSI) and clinical sepsis (CS).
The first survey conducted in September 2003 showed that the national HCAI rate was 6.3 per
100 patients surveyed. The 10 years trend has shown progressive reduction to 1.51 per 100
patients surveyed in September 2012. Since the first survey, pneumonia had always been the
most common type of infection occurring in the hospitals followed by either SSI or BSI.
The objective of HCAI surveillance is to reduce HCAI rates. Surveillance can be carried out by
prevalence studies or incidence studies. Incidence studies are essentially cohort studies which
require much more workload. In general, incidence study is better for surveillance as it is
ongoing. It allows for risk factor analysis and gives more robust data. Incidence studies can be
carried out concentrating on a specific infection type eg. BSI, UTI or VAP or on a specific unit eg.
Intensive Care Unit.
Prevalence study on the other hand is essentially cross sectional and for surveillance purposes,
repeated prevalence studies eg. Point prevalence studies are necessary.
The information on infection rates, main infection sites, common microorganisms and the use
of antibiotics varies from one centre to another. For example, a study in the Netherlands
showed that the most common HCAI was SSI (4.8%), followed by respiratory tract infections
1.1%, UTI (1.7%) and BSI (0.5%) (1). A Canadian study reported that the most common HCAI was
UTI (3.4%), followed by pneumonia (3.0%), SSI (2.5%), BSI (1.6%) and Clostridium difficile-
associated diarrhoea (1%)(2). In short, choosing the best method for HCAI surveillance in a
hospital depends on the following factors:
Background
6
Analysis of the baseline situation (prevalence data, earlier results, outbreaks)
Characteristics of the hospital (famous for a specific operation type)
Which resources are available (manpower)
Formulation of clear objectives (eg. To decrease SSI rates following hip operation)
General objective: To reduce healthcare associated infection prevalence / incidence rate
Specific objective:
1. To estimate the total burden (prevalence) of HCAI in hospitals participating in PPS.
2. To determine the characteristic of infection - types of HCAI and organism, pattern of
antibiotic usage, invasive procedures and other predisposing factors of HCAI
3. To provide a standardized tool for hospitals to identify targets for quality improvement
a) Design
It is a hospital wide cross sectional, point prevalence survey. The survey is conducted twice a
year, one day in the month of March and September
b) Population under surveillance
Population under surveillance is all in-patients on the survey day
c) Definitions of an active HCAI
An active healthcare associated infection present on the day of the survey is defined as follows:
1. Signs and symptoms of the infection are present on the survey date OR signs and
symptoms were previously present and the patient is still receiving treatment for that
infection on the survey date AND
Objectives
Methodology
7
2. The onset of infection was after 48 hours of admission OR
3. The onset of infection (SSI) was less than 48 hours of admission but patient has
undergone surgical procedure within one month or one year (with implant) OR
4. Patient presents with an infection but has been readmitted within 48 hours after a
previous discharge from hospital OR
5. Infections occurring in infants that result from passage through the birth canal are
considered HCAIs if they meet the definition of HCAI.
SUMMARY OF HCAI CASE DEFINITION
Onset of HCAI1 Case definition
After 48 hours AND Meets the case definition on the day of survey
OR
Before 48 hours: SSI criteria met at any time after admission (including previous surgery 30 days/1 year)
OR
OR Before 48 hours AND patient discharged from hospital in preceding 48 hours
OR
Before 48 hours AND patient discharged from hospital in preceding 28 days if CDI2
present
Patient is receiving treatment3 and HCAI has previously met the case definition before 48 hours of treatment and survey day OR
Before 48 hours AND patient has relevant device inserted on this admission prior to onset
8
1. Date of onset of HCAI: date of first signs or symptoms of the infection; if unknown, record the date when treatment was started for this infection or the date the first diagnosis sample was taken. If no treatment or sample, please estimate. Not to be recorded if signs/symptoms are present at admission
2. CDI : Clostridium difficile infection 3 . Any kind of treatment, not necessarily antimicrobial Definitions of the most common HCAI are listed as in Appendix 1. The method of case
confirmation can be made through clinical signs and symptoms or laboratory investigations.
Since this is a hospital wide infection, all patients present in the hospital at the time of survey
are included. The total number of patients is collected in the early morning census from each
ward obtained from the ward sister excluding the psychiatric ward and labour room.
d) Calculation of HCAI Prevalence
Numerator: Any patient that met the criteria in Appendix 1
Denominator: Number of hospitalized patients in the hospital on the day of survey**
Ward HCAI prevalence = No. of patient with HCAI in the ward on the day of survey X 100 No. of hospitalized patients in the ward on the day of survey
Department / discipline HCAI prevalence = No. of patient with HCAI in the department on the day of survey X 100 No. of hospitalized patients in the department on the day of survey
9
Hospital HCAI prevalence = Total no. of patient with HCAI in the hospital on the day of survey X 100 No. of hospitalized patients in the hospital on the day of survey ** Total number of hospitalized patients present at 8.00 am in the hospital on the day of survey
excluding the psychiatric ward and labour room.
e) Inclusion and Exclusion criteria
Ward
Include:
All wards in the hospitals
Exclude:
Psychiatric ward
Labour room/suite
Department
Include:
All Departments in the hospitals
Exclude:
A & E departments (except for wards attached to A&E departments where patients are
monitored for more than 24 hours)
Psychiatric Department
Hospitals
Include:
All selected MOH hospitals and University hospitals
10
Include:
All patients admitted to the ward before or at 8 a.m. and not discharged from the ward
at the time of the survey; in practice, this means that patients transferred in/out after 8
a.m. from/to another ward should not be included.
Neonates on pediatric and O&G wards if born before/at 8 a.m.
Patients who are temporarily off from the ward for diagnostic investigations or
procedures; if patient does not return to the ward before the end of the PPS day and
information about patient is not available at 8 a.m., please revisit ward.
Exclude:
Patients undergoing same day treatment or surgery
Patients seen at outpatient department
Dialysis patients (outpatients)
f) Survey Instrument
Data on infection are obtained from the patients records. HCAI cases are to be supported with
other pertinent information which are being collected in the survey. This includes the
microbiological report, indicating the type of specimen where organism(s) was isolated and the
organism antibiotic susceptibility results.
Information regarding antibiotic treatment received in the past 2 weeks as well as current
antibiotic treatment ie. the patient is still receiving antibiotics for an infection on the day of the
survey is also documented. The current antibiotic treatment indicates that the infection is
active.
It is important to determine the possible source or point where the infection was introduced
during his stay in the hospital. Therefore, information on various types of devices that the
patient had been subjected to is also recorded. Besides the devices, the other possible
contributing factors such as patient’s underlying disease, immunosuppressive therapy,
prolonged hospitalisation, invasive procedures, pre-maturity and low birth weight are looked
into.
Patients
11
Data collection process
Pre survey task
Data collection activity in the hospitals will be handled by the hospital infection control
committee that consists of:
Infection Control Doctor / Clinical Microbiologist
Ward Doctors
Matron / Nurse Manager Infection Control Unit
Infection Control Sister
Infection Control Nurses
Ward Sisters In Charge
Link Nurses
The committee will organized the pre-survey training program if required, scheduling of survey,
coordinate survey data collection (resources identification) until data compilation and report at
the hospital level.
National level
Choose date for survey
Send letter informing date of survey to all participating hospitals address to Director of
Hospital and Infection Control Nurse.
Hospital Level
Inform the administrators and managers of the PPS date
Recruit surveyors
Prepare pre-survey briefing – explain case definition, go through on how format should be
filled
12
Day of survey
Post survey task
Train team to review medical and nursing charts and interview the ward staff.
Assign groups to wards, prepare timetable
Prepare enough copies of formats and forms required
Identify and designate ward sisters to help surveyors
Inform ward sisters to have patient folders at bedside with all investigation reports available
Hospital Level
Visit every patient in the hospital on the survey day at 8 am
Identify infected patients through the case notes (BHT, nursing observation forms,
prescription sheets and laboratory results)
Fill the appropriate surveillance form
For ward sister in charge:
Prepare ward census of patients at 8 am
Identify patients who are temporarily not in the ward (e.g to OT, X ray, rehab , HD)and
inform team when they return to the ward
Hospital Level
Compile all filled forms from team members and send them to state
Tabulate data and calculate HCAI rates
Presentation of result at hospital infection control committee
Disseminate and use data in decision making at hospital level
Formulate Infection control strategies and policies
13
Compilation of data and report
State Level
Collect data from the hospitals in state and send to national secretariat
Tabulate data at state level and calculate HCAI rates
Presentation of result at state infection control committee
Disseminate and use data in decision making at state level
Formulate infection control strategies and policies
National level
Compile all data from the state.
Data analysis and reporting at national level
Presentation of the result during technical and national infection and antibiotic control
committee meeting
Disseminate and use data in decision making at national level
Formulate infection control strategies and policies
Once a case is being identified from the case notes (case identification is made based on the
definition as discussed earlier) the ward infection / link nurse need to fill in the HCAI-
PPS/MOH/2013/1 form as in Appendix 2. Data from each format are then entered and
tabulated according to the form HCAI-PPS/MOH/2013/2 [Excel Format] as in Appendix 3.
Individual form of HCAI-PPS/MOH/2013/1 and HCAI-PPS/MOH/2013/2 are to be sent to
hospital infection control nurse (ICN). The ICN will then compile the data using HCAI-
PPS/MOH/2013/3 [Excel Format] as in Appendix 4 and complete the line listing. Completed
HCAI-PPS/MOH/2013/3 form to be e-mailed to ICN State Coordinator for compilation.
State Coordinator will compile HCAI-PPS/MOH/2013/3 from all hospitals and e-mail them to
the Infection Control Unit, Medical Development Division within 1 month of the PPS date.
However, hospitals are most welcome to produce their own performance report.
14
The national secretariat will compile all the data from the state and produce a report on the
national performance of the HCAI. The flow chart for the case finding and process of the
surveillance is shown in Algorithm for Healthcare Associated Infection Surveillance through
PPS.
15
Surveillance team arrives in the
ward. Record start date and time.
Collect denominator data on all
patients in ward before 8 am
Walk around ward. For each patient,
observe for invasive devices (UC, PVC,
CVC, ventilation)
Collect ONE set of patient notes (medical, nursing,
observation, I/O, drug chart, etc.)
Confirm HCAI according to standard definitions
Ward link nurse to fill in HCAI-PPS/MOH/2013/1 form
Complete data collection for all patients
Compile all the forms and get the no. of
HCAI cases according to type of
infection. Complete the HCAI-
PPS/MOH/2013/2.
ICN to fill in the HCAI-PPS/MOH/2013/3 format based on HCAI-PPS/MOH/2013/2
compiled from the ward.
1) Compilation of HCAI-PPS/MOH/2013/1 to be sent
to hospital ICN
2) Completed HCAI-PPS/MOH/2013/2 to be sent to
ICN in soft copy
State Coordinator to e-mail HCAI-PPS/MOH/2013/3 to
Infection Control Unit, MOH within 1 month of PPS date
Line listing to be filled and kept
at the hospital
If note are unclear, ask
for clarification of sign
and symptom from
nursing/medical team
ICN to send the HCAI-PPS/MOH/2013/3 to state coordinator
ICN to complete the line listing
Data management by
Infection Control Unit, MOH
Algorithm for healthcare associated infection surveillance through PPS
16
DEFINITIONS OF HEALTHCARE ASSOCIATED INFECTIONS – FIRST EDITION 2013
This document has been adapted from the CDC/NHSN Surveillance Definition of Healthcare Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting and European Centre for Disease Prevention and Control, Point prevalence survey of healthcare associated infections and antimicrobial use in European acute care hospitals- protocol version 4.3. Stockholm: ECDC; 2012 Most HCAI becomes evident 48 hours (i.e., the typical incubation period) or more after admission. However, because the incubation period varies with the type of pathogen, nature of infection and the patient’s underlying conditions, each patient must be assessed individually for evidence that links it to the hospitalization. The diagnosis of a HCAI is based on a combination of clinical and laboratory findings. There are two special situations in which an infection is considered HCAI:
1. Infection that is acquired in the hospital but does not become evident until after hospital discharge.
2. Infections occurring in infants that result from passage through the birth canal are considered HCAIs if they meet the definition of HCAI above
There are two special situations in which an infection is not considered HCAI:
1. Infection that is associated with a complication or extension of infection already present on admission, unless a change in pathogen or symptoms strongly suggests the acquisition of a new infection.
2. In an infant an infection that is known or proved to have been acquired transplacentally (e.g., toxoplasmosis, rubella, cytomegalovirus, or syphilis) and becomes evident at or before 48 hours after birth.
For the purpose of our survey, only the most common HCAI i.e. urinary tract infection, pneumonia, surgical site infections, blood stream infections and clinical sepsis will be defined precisely. For other HCAI record them as OTHERS and briefly describe the nature of the infection as best you can. The following pages contain the criteria to be used for diagnosing the common HCAI. If you are in doubt PLEASE CONSULT THE ATTENDING DOCTOR OR MICROBIOLOGIST
APPENDIX 1
17
INFECTION SITE: Symptomatic urinary tract infection CODE: UTI DEFINITION: A symptomatic urinary tract infection must meet at least one of the following criteria:
Criterion Description
1 Patient had an indwelling urinary catheter in place for >48 hours, with day of device placement being Day 1, and catheter was in place at the time when all elements of this criterion were first present together. And at least 1 of the following signs or symptoms: fever (>38°C); suprapubic tenderness*; costovertebral angle pain or tenderness* And a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms. OR Patient had an indwelling urinary catheter in place for >48 hours and had it removed the day of or the day before all elements of this criterion were first present together And at least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*; dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness* And a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms. *With no other recognized cause
2 Patient had an indwelling urinary catheter in place for >48 hours, with day of device placement being Day 1 and catheter was in place when all elements of this criterion were first present together And
18
at least 1 of the following signs or symptoms: fever (>38°C); suprapubic tenderness*; costovertebral angle pain or tenderness* And at least 1 of the following findings: a. positive dipstick for leukocyte esterase and/or nitrite b. pyuria (urine specimen with ≥10 white blood cells [WBC]/mm3 of unspun urine or >5 WBC/high power field of spun urine) c. microorganisms seen on Gram’s stain of unspun urine And a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms. OR Patient with an indwelling urinary catheter in place for > 48 hours and had it removed the day of or the day before all elements of this criterion were first present together And at least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*; dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness* And at least 1 of the following findings: a. positive dipstick for leukocyte esterase and/or nitrite b. pyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or >5 WBC/high power field of spun urine c. microorganisms seen on Gram’s stain of unspun urine And a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms. *With no other recognized cause
For patient ≤1 year of age
19
Criterion Description
3 Patient ≤1 year of age with** or without an indwelling urinary catheter has at least 1 of the following signs or symptoms: fever (>38°C core); hypothermia (<36°C core); apnea*; bradycardia*; dysuria*; lethargy*; vomiting* And a positive urine culture of ≥105 CFU/ml with no more than 2 species of microorganisms. Elements of the criterion must occur within a timeframe that does not exceed a gap of 1 calendar day. *With no other recognized cause ** Patient had an indwelling urinary catheter in place for > 48 hours, with day of device placement being Day 1, and catheter was in place when all elements of this criterion were first present together.
4 Patient ≤1 year of age with** or without an indwelling urinary catheter has at least 1 of the following signs or symptoms: fever (>38°C core); hypothermia (<36°C core); apnea*; bradycardia*; dysuria*; lethargy*; vomiting* And at least 1 of the following findings: a. positive dipstick for leukocyte esterase and/or nitrite b. pyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or >5 WBC/high
power field of spun urine c. microorganisms seen on Gram’s stain of unspun urine And a positive urine culture of between ≥103 and <105 CFU/ml with no more than two species of microorganisms. *With no other recognized cause ** Patient had an indwelling urinary catheter in place for > 48 hours, with day of device placement being Day 1 and catheter was in place when all elements of this criterion were first present together
INFECTION SITE: Asymptomatic bacteriuria
20
CODE: ASB DEFINITION: An asymptomatic bacteriuria must fulfill the criterion described below
Criterion Description
Patient with* or without an indwelling urinary catheter has no signs or symptoms (i.e., for any age patient, no fever (>38°C); urgency; frequency; dysuria; suprapubic tenderness; costovertebral angle pain or tenderness OR for a patient ≤1 year of age; no fever (>38°C core); hypothermia (<36°C core); apnea; bradycardia; dysuria; lethargy; or vomiting) And a positive urine culture of ≥105 CFU/ml with no more than 2 species of uropathogen microorganisms** (see Comments section below). And a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture, or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin commensal. *Patient had an indwelling urinary catheter in place for > 48 hours, with day of device placement being Day 1, and catheter was in place when all elements of this criterion were first present together. **Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus spp., yeasts, beta-hemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae, and Corynebacterium (urease positive)+. +Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C. urealyticum (CORUR) if so speciated.
INFECTION SITE: Surgical Site Infection (Superficial Incisional)
21
CODE: SSI-(Skin)
DEFINITION: A superficial SSI must meet the following criterion:
Infection occurs within 30 days after any operative procedure and involves only skin and
subcutaneous tissue of the incision and patient has at least one of the following:
a. purulent drainage from the superficial incision
b. organsims isolated from an aseptically-obtained culture of fluid or tissue from the
superficial incision
c. superficial incision that is deliberately opened by a surgeon and is culture-positive or
not cultured
and
patient has at least one of the following signs or symptoms of infection: pain or
tenderness; localized swelling; redness; or heat. A culture negative finding does not
meet this criterion
d. diagnosis of superficial incisional SSI by the surgeon or attending physician
INFECTION SITE: Surgical site infection (Deep incisional)
CODE: SSI-(Soft Tissue)
DEFINITION: A deep incisional SSI must meet the following criterion:
Infection occurs within 30 days after the NHSN operative procedure according to the list in
Table 1
Or
Infection occurs within 90 days after the NHSN operative procedure according to the list in
Table 2
And
Involve deep soft tissues of the incision (e.g., fascial and muscle layers)
And
Patient has at least one of the following:
a. purulent drainage from the deep incision
22
b. a deep incision that spontaneously dehisces or is deliberately opened by a surgeon and
is culture-positive or not cultured
And Patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or tenderness. A culture-negative finding does not meet this criterion. c. an abscess or other evidence of infection involving the deep incision is found on direct examination, during invasive procedure, or by histopathologic examination or imaging test. d. diagnosis of a deep incisional SSI by a surgeon or attending physician. Table 1. 30 day Surveillance Period for Deep Incisional or Organ/Space SSI Following Selected NHSN Operative Procedure Categories
23
30-day Surveillance
Code Operative Procedure Code Operative Procedure
AAA Abdominal aortic aneurysm repair
LAM Laminectomy
AMP Limb amputation LTP Liver transplant
APPY Appendix surgery NECK Neck surgery
AVSD Shunt for dialysis NEPH Kidney surgery
BILI Bile duct, liver or pancreatic surgery
OVRY Ovarian surgery
CEA Carotid endarterectomy
PRST Prostate surgery
CHOL Gallbladder surgery REC Rectal surgery
COLO Colon surgery SB Small bowel surgery
CSEC Cesarean section SPLE Spleen surgery
GAST Gastric surgery THOR Thoracic surgery
HTP Heart transplant THYR Thyroid and/or parathyroid surgery
HYST Abdominal hysterectomy
VHYS Vaginal hysterectomy
KTP Kidney transplant XLAP Exploratory laparotomy
OTH Other operative procedures not included in the NHSN categories
Table 2. 90 day Surveillance Period for Deep Incisional or Organ/Space SSI Following Selected NHSN Operative Procedure Categories
24
90-day Surveillance
Code Operative Procedure
BRST Breast surgery
CARD Cardiac surgery
CBGB Coronary artery bypass graft with both chest and donor site incisions
CBGC Coronary artery bypass graft with chest incision only
CRAN Craniotomy
FUSN Spinal fusion
FX Open reduction of fracture
HER Herniorrhaphy
HPRO Hip prosthesis
KPRO Knee prosthesis
PACE Pacemaker surgery
PVBY Peripheral vascular bypass surgery
RFUSN Refusion of spine
VSHN Ventricular shunt
INFECTION SITE: Surgical site infection (organ/space) CODE: SSI-(Specify site of organ/space)
25
DEFINITION: An organ/space SSI involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure. An organ/space SSI must meet the following criterion: Infection occurs within 30 days after the NHSN operative procedure according to the list in Table 1 Or Infection occurs within 90 days after the NHSN operative procedure according to the list in Table 2 And Infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure And Patient has at least 1 of the following: a. purulent drainage from a drain that is placed into the organ/space b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space c. an abscess or other evidence of infection involving the organ/space that is found on direct
examination, during invasive procedure, or by histopathologic examination or imaging test d. diagnosis of an organ/space SSI by a surgeon or attending physician. And meets at least one criterion for a specific organ/space infection site listed in Table 3. Table 3. Specific Site of Organ/Space SSI
26
Code Site Code Site
BONE Osteomyelitis JNT Joint or bursa
BRST Breast abscess or mastitis LUNG Other infections of the respiratory tract
CARD Myocarditis or pericarditis MED Mediastinitis
DISC Disc space MEN Meningitis or ventriculitis
EAR Ear, mastoid ORAL Oral cavity (mouth, tongue, or gums)
EMET Endometritis OREP Other infections of the male or female reproductive tract
ENDO Endocarditis OUTI Other infections of the urinary tract
EYE Eye, other than conjunctivitis
SA Spinal abscess without meningitis
GIT GI tract SINU Sinusitis
HEP Hepatitis UR Upper respiratory tract
IAB Intraabdominal, not specified elsewhere
VASC Arterial or venous infection
IC Intracranial, brain abscess or dura
VCUF Vaginal cuff
Wound class An assessment of the degree of contamination of a surgical wound at the time of the operation. Wound class should be assigned by a person involved in the surgical procedure, e.g., surgeon, circulating nurse, etc. The wound class system used in NHSN is an adaptation of the American College of Surgeons wound classification schema. Wounds are divided into four classes: 1. Clean An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. NOTE:
27
The following NHSN operative procedure categories are NEVER considered to have a clean wound classification: APPY, BILI, CHOL, COLO, REC, SB, and VHYS. 2. Clean Contaminated An operative wounds in which the respiratory, alimentary, genital or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. Includes female and male reproductive tracts. 3. Contaminated Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category. 4. Dirty or Infected Includes old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation INFECTION SITE: Pneumonia CODE: PNEU DEFINITION:
1. Clinically-defined pneumonia which must fulfill the following criteria:
Radiology Signs/Symptoms/Laboratory
Two or more serial chest radiographs with at least one of the following: • New or progressive and persistent infiltrate • Consolidation • Cavitation
FOR ANY PATIENT, at least one of the following: • Fever (>38°C) • Leukopenia (<4000 WBC/mm3) or leukocytosis (≥12,000 WBC/mm3) • For adults ≥70 years old, altered mental status with no other recognized cause and at least two of the following: • New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements • New onset or worsening cough, or dyspnea, or tachypnea
28
• Pneumatoceles, in infants ≤1 year old NOTE: In patients without underlying pulmonary or cardiac disease (e.g., respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), one definitive chest radiograph is acceptable.1
• Rales or bronchial breath sounds • Worsening gas exchange (e.g., O2 desaturations (e.g., PaO2/FiO2 ≤240)7, increased oxygen requirements, or increased ventilator demand)
ALTERNATE CRITERIA, for infants <1 year old: Worsening gas exchange (e.g., O2 desaturations [e.g., pulse oximetry <94%], increased oxygen requirements, or increased ventilator demand) and at least three of the following: • Temperature instability • Leukopenia (<4000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3) and left shift (≥10% band forms) • New onset of purulent sputum or change in character of sputum4, or increased respiratory secretions or increased suctioning requirements • Apnea, tachypnea , nasal flaring with retraction of chest wall or grunting • Wheezing, rales, or rhonchi • Cough • Bradycardia (<100 beats/min) or tachycardia (>170 beats/min)
ALTERNATE CRITERIA, for child >1 year old or ≤12 years old, at least three of the following: • Fever (>38.4°C) or hypothermia (<36.5°C) • Leukopenia (<4000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3) • New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements • New onset or worsening cough, or dyspnea, apnea, or tachypnea. • Rales or bronchial breath sounds • Worsening gas exchange (e.g., O2 desaturations [e.g., pulse oximetry <94%], increased oxygen requirements, or increased ventilator demand)
29
Radiology
Signs/Symptoms
Laboratory
Two or more serial chest radiographs with at least one of the following1,2: New or progressive and
persistent infiltrate Consolidation Cavitation Pneumatoceles, in infants
≤1 year old NOTE: In patients without underlying pulmonary or cardiac disease (e.g., respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), one definitive chest radiograph is acceptable.1
At least one of the following:
Fever (>38°C or >100.4°F)
Leukopenia (<4000 WBC/mm3) or leukocytosis (≥12,000 WBC/mm3)
For adults ≥70 years old, altered mental status with no other recognized cause
and at least one of the following:
New onset of purulent sputum3, or change in character of sputum4, or increased respiratory secretions, or increased suctioning requirements
New onset or worsening cough, or dyspnea or tachypnea5
Rales6 or bronchial breath sounds
Worsening gas exchange (e.g., O2 desaturations [e.g., PaO2/FiO2 ≤240]7, increased oxygen requirements, or increased ventilator demand)
At least one of the following: • Positive growth in blood
culture8 not related to another source of infection
• Positive growth in culture
of pleural fluid • Positive quantitative
culture9 from minimally contaminated LRT specimen (e.g., BAL or protected specimen brushing)
• ≥5% BAL-obtained cells
contain intracellular bacteria on direct microscopic exam (e.g., Gram’s stain)
• Histopathologic exam
shows at least one of the following evidences of pneumonia:
Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli
Positive quantitative culture9 of lung parenchyma
Evidence of lung parenchyma invasion by fungal hyphae or pseudohyphae
2. Specific Site Algorithms for Pneumonia with Common Bacterial or Filamentous Fungal Pathogens and Specific Laboratory Findings (PNU2)
30
Table 4. Threshold Values for Cultured Specimens Used in the Pneumonia Criteria
Specimen collection/technique Values
Lung parenchyma* ≥104 CFU/g tissue
Bronchoscopically (B) obtained specimens
Bronchoalveolar lavage (B-BAL) ≥104 CFU/ml
Protected BAL (B-PBAL) ≥104 CFU/ml
Protected specimen brushing (B-PSB) ≥103 CFU/ml
Nonbronchoscopically (NB) obtained (blind) specimens
NB-BAL >104 CFU/ml
NB-PSB ≥103 CFU/ml
CFU = colony forming units g = gram ml = milliliter * Open-lung biopsy specimens and immediate post-mortem specimens obtained by transthoracic or transbronchial biopsy INFECTION SITE: Ventilator-associated PNEU (VAP) CODE: VAP DEFINITION: A pneumonia where the patient is on mechanical ventilation for >48 hours on the date of event, with day of ventilator placement being Day 1, and the ventilator was in place on the date of event or the day before. If the patient is admitted or transferred into a facility on a ventilator, the day of admission is considered Day1. and Fulfill either Criteria in Table 1 or 2
31
Ventilator: A device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation. NOTE: Lung expansion devices such as intermittent positive-pressure breathing (IPPB); nasal positive
end-expiratory pressure (PEEP); and continuous nasal positive airway pressure (CPAP,
hypoCPAP) are not considered ventilators unless delivered via tracheostomy or endotracheal
intubation (e.g., ET-CPAP).
32
INFECTION SITE: Laboratory-confirmed bloodstream infection (LCBI) CODE: BSI DEFINITION: Laboratory-confirmed bloodstream infection must meet at least one of the following criteria:
Criterion Description
LCBI 1 Patient has a recognized pathogen cultured from one or more blood cultures And organism cultured from blood is not related to an infection at another site.
LCBI 2 Patient has at least one of the following signs or symptoms: fever (>38°C), chills*, or hypotension* And positive laboratory results are not related to an infection at another site And common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., and Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. Criterion elements must occur within a timeframe that does not exceed a gap of 1 calendar day *With no other recognized cause
LCBI 3 Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever (>38oC core) hypothermia (<36°C core), apnea*, or bradycardia* And positive laboratory results are not related to an infection at another site And common skin commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. Criterion elements must occur within a timeframe that does not exceed a gap of 1 calendar day *With no other recognized cause
33
INFECTION SITE: Catheter Associated Blood Stream Infection (CABSI) CODE: CABSI DEFINITION: A laboratory-confirmed bloodstream infection where a catheter either central or peripheral
was in place for >48 hours on the date of event, with day of device placement being Day 1.
and
a central or peripheral catheter was in place on the date of event or the day before. If a
catheter was in place for >48 hours and then removed, the LCBI criteria must be fully met on
the day of discontinuation or the next day. If the patient is admitted or transferred into a
facility with a central line in place (e.g., tunneled or implanted central line), day of first access is
considered Day 1.
EXAMPLES:
• Patient in ICU has central line inserted/accessed on June 1. On June 3, the central line is still in
place and the patient has positive blood culture with S. aureus. This is a CLABSI because the
central line was in place for >2 calendar days when all elements of LCBI Criterion 1 were first
present together (date of event).
• Patient has a central line inserted on June 1. On June 3, the central line is removed and on
June 4 the patient has a positive blood culture with S. aureus. This is a CLABSI because the
central line was in place for >2 calendar days (June 1, 2, and 3) and was in place the day before
all elements of LCBI Criterion 1 were first present together (date of event).
• On June 3, central line is removed and on June 4 patient spikes a fever of 38.3°C. Two blood
culture sets collected on June 5 are positive for S. epidermidis. This is may be a healthcare-
associated bloodstream infection but it is not a CLABSI because the central line was not place
the day of or the day before all elements of LCBI Criterion 2 were first present together (June
5).
LABORATORY DIAGNOSIS
1. For suspected CRBSI, paired blood samples, drawn from the catheter and a peripheral
vein, should be cultured before initiation of antimicrobial therapy, and the bottles
34
should be appropriately marked to reflect the site from which the samples were
obtained
2. If a blood sample cannot be drawn from a peripheral vein, it is recommended that 2
blood samples should be drawn through different catheter lumens. It is unclear whether
blood cultures should be drawn through all catheter lumens in such circumstances.
3. A definitive diagnosis of CRBSI requires that the same organism grow from at least 1
percutaneous blood culture and from a culture of the catheter tip, or that 2 blood
samples be drawn (one from a catheter hub and the other from a peripheral vein) that,
when cultured, meet CRBSI criteria for quantitative blood cultures or differential time to
positivity (DTP).
4. Alternatively 2 quantitative blood cultures of samples obtained through 2 catheter
lumens in which the colony count for the blood sample drawn through one lumen is at
least 3-fold greater than the colony count for the blood sample obtained from the
second lumen should be considered to indicate possible CRBSI
5. For DTP, growth of microbes from a blood sample drawn from a catheter hub at least 2
h before microbial growth is detected in a blood sample obtained from a peripheral vein
best defines CRBSI
6. For quantitative blood cultures, a colony count of microbes grown from blood obtained
through the catheter hub that is at least 3-fold greater than the colony count from
blood obtained from a peripheral vein best defines CRBSI.
7. Catheter cultures should be performed when a catheter is removed for suspected
catheter-related bloodstream infection (CRBSI. For central venous catheters (CVCs), the
catheter tip should be cultured.
8. Growth of >15 colony-forming units (cfu) from a 5-cm segment of the catheter tip by
semiquantitative (roll plate) culture or >102 cfu from a catheter by quantitative
(sonication) broth culture reflects catheter colonization
35
Central line: An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. The following are considered great vessels for the purpose of reporting CLABSI or CABSI • Aorta
• Pulmonary artery
• Superior vena cava
• Inferior vena cava
• Brachiocephalic veins
• Internal jugular veins
• Subclavian veins
• External iliac veins
• Common iliac veins
• Femoral veins
• In neonates, the umbilical artery/vein.
NOTES:
1. Neither the insertion site nor the type of device may be used to determine if a line
qualifies as a central line. The device must terminate in one of the great vessels or in or
near the heart and be used for one of the purposes outlined above, to qualify as a
central line.
2. An introducer is considered an intravascular catheter, and depending on the location of
its tip and use, may be a central line.
3. Pacemaker wires and other nonlumened devices inserted into central blood vessels or
the heart are not considered central lines, because fluids are not infused, pushed, nor
withdrawn through such devices.
4. The following devices ARE NOT considered central lines:
• Extracorporeal membrane oxygenation (ECMO)
36
• Femoral arterial catheters
• Intraaortic balloon pump (IABP) devices.
Infusion: The introduction of a solution through a blood vessel via a catheter lumen. This may include continuous infusions such as nutritional fluids or medications, or it may include intermittent infusions such as flushes, IV antimicrobial administration, or blood transfusion or hemodialysis. Umbilical catheter: A central vascular device inserted through the umbilical artery or vein in a neonate. Temporary central line: A non-tunneled or implanted catheter. Permanent central line: Includes
• Tunneled catheters, including certain dialysis catheters
• Implanted catheters (including ports)
INFECTION SITE: Clinical Sepsis CODE: CS DEFINITION: Infection involving multiple organs or systems, without an apparent single site of infection in
adults and children in which the patient has at least one of the following criteria:
− clinical signs or symptoms with no other recognised cause;
− fever (38 °C);
− hypotension (systolic pressure < 90 mm);
− or oliguria (20 cm3(ml)/hr);
And − blood culture not done or no organisms or antigen detected in blood; And − no apparent infection at another site; And
37
− Physician institutes treatment for sepsis. Clinical sepsis in neonates All of the three following criteria:
• supervising physician started appropriate antimicrobial therapy for sepsis for at least five
days;
• no detection of pathogens in blood culture or not tested;
• no obvious infection at another site;
And two of the following criteria (without other apparent cause):
− fever (> 38 °C) or temperature instability (frequent post-set of the incubator) or hypothermia
(< 36.5°C);
− tachycardia (> 200/min) or new /increased bradycardia (< 80/min);
− capillary refilling time (CRT) > 2s;
− new or increased apnoea(s) (> 20s);
− unexplained metabolic acidosis;
− new-onset hyperglycemia (> 140mg/dl);
− another sign of sepsis (skin colour (only if the CRT is not used), laboratory signs (CRP,
interleukin) and increased oxygen requirement (intubation), unstable general condition of the
patient, apathy)
38
Healthcare Associated Infection Surveillance Form
(HCAI-PPS/MOH/2013/1)
A. CASE IDENTIFICATION DATA
Name : _______________________________
I/C or Passport No: ______________________
RN :___________________________________
Gender : Male/ Female
Age: _____
Hospital :______________________________
Department : ___________________________
Ward:_________________________________
Date of Admission:_______________________
B. CLINICAL DATA
i. Clinical Diagnosis
____________________________________________________________________
ii. General predisposing risk factors [√ where appropriate]
a. Underlying disease (eg; Diabetes/ Malignancy/ Kidney Disease) Specify
b. Immunosuppressive therapy
c. Prolonged hospitalization > 2 weeks
d. Prematurity / Low Birth Weight
e. Surgery within 1 month / 1 year (with implant)
f. Others Specify
APPENDIX 2
39
iii. Type of devices used before the onset of HCAI [ √ where appropriate ]
Device Date of insertion
a. Indwelling urinary catheter _________________
b. Mechanical ventilator _________________
c. Tracheostomy _________________
d. Central venous catheter _________________
e. Arterial line _________________
f. Peripheral venous line _________________
g. Other drainage catheters _________________
Specify……………………………………………………
iv. Antibiotic therapy given in the past 2 weeks [ √ where appropriate ]
No. Name and Group of
Antibiotic
Indication
Date commenced
Route of admission
Duration (days)
Meet local
policy
(Y/N/NK)*
Emp
iric
al
Ther
apeu
tic
Pro
ph
ylax
is
* Y-YES, N-NO, NK-Not known
C. MICROBIOLOGICAL DATA (Please attach the relevant positive C&S report)
Date of collection
Date of lab report
Type of specimen
Organism isolated
Antibiotic susceptibility report
40
D. OUTCOME DATA [ √ where appropriate ]
Type of infection
Method of detection
Clinical Laboratory
1. Surgical site infection (SSI)
Type of SSI
a. Superficial incisional
b. Deep incisional
c. Organ or space
Type of SSI wound
a. Clean wound
b. Clean contaminated wound
c. Contaminated wound
d. Dirty wound
2. Urinary tract infection
3. Pneumonia
a. Hospital acquired pneumonia (other than VAP)
b. Ventilator associated pneumonia (VAP)
4. Blood stream infection
a. Blood stream infection (other than CABSI)
b. Catheter associated blood stream infection (CABSI)
5. Clinical sepsis
6. Others Specify ………………………………………………………
Reported by: Signature: ________________________ Name and Designation:_____________________ Date: ____________________________
41
APPENDIX 3
42
43
44
APPENDIX 4
45
Device No. of Patient Percentage
a. Indwelling urinary catheter #DIV/0!
b. Mechanical ventilator #DIV/0!
c. Tracheostomy #DIV/0!
d. Central venous catheter #DIV/0!
e. Arterial line #DIV/0!
f. Peripheral venous line #DIV/0!
g. Other drainage catheters #DIV/0!
Antibiotic Therapy No. of Patient Percentage
a. Aminoglycosides #DIV/0!
b. Carbapenems #DIV/0!
c. Cephalosporins #DIV/0!
d. Penicillins #DIV/0!
e. Vancomycin #DIV/0!
f. B-lactam/B-lactamase inhibitor #DIV/0!
g. Fluoroquinolones #DIV/0!
a. Empirical #DIV/0!
b. Therapeutic #DIV/0!
c. Prophylaxis #DIV/0!
a. Less than 3 days #DIV/0!
b. 3 to 7 days #DIV/0!
c. More than 3 days #DIV/0!
4. Meet Local policy #DIV/0!
a. Yes #DIV/0!
b. No #DIV/0!
c. Not known #DIV/0!
3. Duration of Antibiotic
2. Indication of Antibiotic
1. Group of Antibiotic
46
Organism isolated No. of Patient Percentage
MRSA #DIV/0!
Staph. aureus #DIV/0!
P.Aeruginosa - MRO #DIV/0!
P.Aeruginosa - Non MRO #DIV/0!
K.Pneumo - ESBL #DIV/0!
K.Pneumo - Non ESBL #DIV/0!
E.coli - ESBL #DIV/0!
E.coli - Non ESBL #DIV/0!
CON Staph #DIV/0!
Acineto spp- MRO #DIV/0!
Acineto spp- Non MRO #DIV/0!
Enterobac gp #DIV/0!
CRE #DIV/0!
Others #DIV/0!
HCAI Rate for the Hospital =
= #VALUE!
Reported by: Verified by:
Date:___________________________________ Date:______________________________________
No. of patient in the Hospital on the Day of Survey
Signature: ______________________________ Signature: _________________________________
Name and Designation:___________________ Name and Designation: ______________________
______________No. of Patient with HCAI ___________ x 100
47
APPENDIX 5
48
References
1. Mermel LA et al. Clinical Practice Guidelines for the Diagnosis and Management of
Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases
Society of America: Clinical Infectious Diseases 2009; 49:1–45
2. Van der Kooi TII et al. Prevalence of nosocomial infections in The Netherlands, 2007-
2008: results of the first four national studies. Journal of Hospital Infection 75 (2010)
168-172
3. Gravel D et al. Point prevalence survey for healthcare-associated infections within
Canadian adult acute-care hospitals. Journal of Hospital Infection 67 (2007) 243-248
4. European Centre for Disease Prevention and Control. Point prevalence survey of
healthcareassociated infections and antimicrobial use in European acute care
hospitals – protocol version 4.3. Stockholm: ECDC; 2012
5. CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for
Specific Types of Infections in the Acute Care Setting, January 2013
6. July 2013 CDC/NHSN Protocol Clarifications
7. Fourth National Point Prevalence Survey on Healthcare Associated Infections and
First National Point Prevalence Survey on Antimicrobial Use and Quality Indicators in
England July 2011