Healthcare Infection Surveillance Of Western Australia

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Healthcare InfectionSurveillance ofWestern Australia (HISWA)Surveillance ManualVersion 7, January

This publication has been produced by theHealthcare Associated Infection Unit,Communicable Disease Control Directorate. Department of Health, Western AustraliaJanuary 2020Contributors / EditorsMcCann R, Stirling M, Parker C.Contact DetailsHealthcare Associated Infection UnitCommunicable Disease Control DirectorateDepartment of Health Western AustraliaPO Box 8172Perth Business CentreWestern Australia 6849Telephone: 08 9222 2131Email: ls/Infectious-diseases

ContentsForeword2Module 1 – Introduction to surveillance of healthcare-associated infections4Module 2 – Surgical site infection surveillance13Module 3 – Methicillin-resistant Staphylococcus aureus (MRSA) healthcare associated infection30Module 4 – Clostridioides difficile infection43Module 5 – Vancomycin-resistant enterococci (VRE) sterile site infection52Module 6 – Staphylococcus aureus bloodstream infection62Module 7 – Central line-associated bloodstream infection74Module 8 – Haemodialysis access-associated bloodstream infection89Module 9 – Occupational exposure99Module 10 – Bed-day and separation data1051

ForewordHealthcare-associated infections (HAIs) are one of the most common causes of unintended harm sufferedby health consumers. These infections cause the patient unnecessary pain and suffering and utilisesignificant human and financial resources within healthcare systems. It is increasingly recognised that HAIsare preventable adverse events rather than an inevitable complication of medical care. Establishment ofbaseline HAI rates and ensuring ongoing monitoring is essential to measure the effectiveness of infectionprevention strategies that are implemented to reduce the occurrence of HAIs.Both private and public healthcare facilities (HCFs) in Western Australia (WA) voluntarily commencedcontributing data to the Healthcare Infection Surveillance WA (HISWA) program in 2005. The introductionof mandatory indicators for all public HCFs and private HCFs contracted to provide care for public patientscommenced in 2007. Private HCFs continue to contribute data to HISWA voluntarily. The indicators collectedfor HISWA are described in Table 1.The goals of the HISWA program are to ensure:*all WA hospitals utilise standardised definitions and methodology*ensure the validity of data through formal and informal validation exercises**trends are identified and clinicians engaged to review clinical care to minimise infection risks and thusreduce the incidence of HAIs activities are aligned, where possible, with Australian and internationalsurveillance programs to allow for relevant external benchmarkingsupport is provided to surveillance personnel contributing data to HISWA.HISWA data is analysed by staff at the Healthcare Associated Infection Unit (HAIU). Aggregated data anddetailed hospital-specific reports are produced and distributed. All contributors are encouraged to internallyreview their own data to identify issues and trends in a timely manner. This surveillance manual containsthe technical information to allow standardised definitions and methodology to be utilised by surveillancepersonnel reporting data to HISWA. If any hospital requires assistance with their surveillance program, theHAIU team are available to provide support.2

Table 1: HISWA indicatorsHISWA IndicatorsHealthcare-associatedinfections due tomethicillin-resistantStaphylococcus aureus(MRSA)Surgical site infectionfollowing hip and kneearthroplastyHealthcare-associatedbloodstream infection dueto Staphylococcus aureus(methicillin-sensitive idioides difficileinfectionCentral line-associatedbloodstream infections inadult intensive care unitsHaemodialysis accessassociated bloodstreaminfection.Healthcare workeroccupational exposure toblood/body fluidsData CollectionCommencedRequirementsfor DataSubmissionJuly 2005July 2005October 2007All data arerequired tobe submittedwithin 30days fromthe end ofthe reportingmonth.January 2010July 2005July 2005January 2008SSI followinghip and kneearthroplastyis subjectto a 90 daysurveillanceperiod.All data shouldbe subjectto internalvalidationprocessesprior tsAny private hospital canvoluntarily submit data toHISWA where the indicator isrelevant to their facilityMandatory(October 2007)Mandatory for all publicmetropolitan, regionalresource centres andintegrated district hospitals.Mandatory(October 2007)Mandatory for all publicmetropolitan, regionalresource centres andintegrated district hospitalswhere arthroplastyprocedures are performed.Mandatory(October 2007)Mandatory for all publicmetropolitan, regionalresource centres andintegrated district hospitals.Mandatory(January 2010)Mandatory for all publicmetropolitan, regionalresource centres andintegrated district hospitals.Mandatory(October 2009)Mandatory for all publichospitals with adultintensive care units.Mandatory(July 2009)Mandatory for all publicmetropolitan, regionalresource centres andintegrated district hospitalswhere haemodialysis isperformed.Mandatory(January 2008)Mandatory for all publicmetropolitan, regionalresource centres andintegrated district hospitals.Any private or public HCFwhere the indicator isrelevant to the provision ofcare.Any private or publicHCF performing theseproceduresHISWA non-mandatory HAI indicatorsCentral line-associatedbloodstream infections inhaematology and oncology.July 2005VoluntaryparticipationSurgical site infectionfollowing caesareansectionApril 2011Voluntaryparticipation3

Module 1Introduction to surveillance ofhealthcare-associated infections4

ContentsIntroduction61.Surveillance overview62.Rationale for surveillance73.Types of HAI surveillance73.1Outcome surveillance73.2Process surveillance74.Selection of surveillance indicators75.Surveillance methodology85.1Active, prospective case-finding85.2Patient-based surveillance85.3Definitions96.Data validation7.Data entry to HISWA108.Data analysis108.1Calculation of rates108.2The p-value108.3Confidence intervals118.4Risk stratification118.5Benchmarking119.9Interpretation of reports119.1WA aggregate rate119.2Cumulative WA aggregate rate119.3Cumulative hospital infections and rate119.4Rate previous two quarters129.5Trend129.6Comparator rate12Infection rates from small hospitals1210.9.7Reporting and feedback12References125

Introduction1. Surveillance overviewSurveillance is the systematic collection, management, analysis, interpretation and reporting of data for usein the planning, implementation and evaluation of the provision of healthcare.1 The purpose of undertakinghealthcare-associated infection (HAI) surveillance is to monitor and support improvement in the quality andsafety of patient care within a healthcare facility (HCF).1Data should not be collected just for the purpose of collecting data – the data need to be used to supportthe implementation of strategies that will reduce the risk of patients acquiring HAIs. Effective surveillancesystems are the drivers for change and make it possible to evaluate the effectiveness of interventions. Aneffective surveillance system is one that provides timely feedback to HCF clinicians and managers to enablechange to happen.2Surveillance complements other prevention strategies including clinical interventions to improve the qualityof care, adoption of evidence-informed practice and outbreak identification and management.The National Safety and Quality Health Service (NSQHS) Standards requires HCFs to perform HAIsurveillance in order to gather data on the incidence and prevalence of infection within their organisation.3A robust surveillance strategy that collects data on HAIs relevant to the size and scope of the HCF, thatmonitors the surveillance data to guide risk reduction strategies and reports on the surveillance data to thekey stakeholders, the governing bodies and the consumers, is required in order to comply with the NSQHSStandards.3Figure 1: Essential components of the surveillance cycleDatacollectionIntervention / qualityimprovementData analysisand interpretationFeedback of datato key stakeholders6

2. Rationale for surveillanceSurveillance of HAIs provides objective data on which to base decisions. Surveillance data enables us todetermine whether a problem exists, identifies the size of the problem, and allows observation of trends overtime. A sound surveillance system should:*determine baseline HAI rates*detect changes in rates or distribution of HAI*facilitate investigation of significant increases in HAI rates*determine the effectiveness of infection prevention measures*monitor compliance with established infection prevention practices*evaluate interventions and change in practice*identify areas where research would be beneficial.13. Types of HAI surveillanceAs it is not practical to conduct facility-wide surveillance for all HAI events, surveillance is often targeted,with a focus on specific sites of infection, specific populations, specific organisms, or specific locationswithin the HCF.1 There are two main methods of surveillance – outcome and process.13.1 Outcome surveillanceOutcome surveillance involves measuring adverse healthcare events, a proportion of which are preventable.1Data may be expressed as:*rates: time-series of HAI counts or proportions.*point prevalence: the proportion of patients with HAIs at the time of the prevalence survey.*incidence over time: the number of patients who develop a new HAI.Examples of outcome surveillance include capturing the incidence of methicillin-resistant Staphylococcusaureus (MRSA) bacteraemia and surgical site infections (SSIs).13.2 Process surveillanceProcess surveillance involves auditing actual practice against evidence-informed infection preventionstrategies that are linked to improved outcomes.1 This methodology is useful because data can be capturedquickly, and can capture instances of inappropriate care that did not actually result in patient harm.1Improved processes should result in lower infection rates.Examples of process surveillance include auditing compliance of antibiotic surgical prophylaxis or bundlesof care for insertion of central lines and hand hygiene compliance.14. Selection of surveillance indicatorsInfection prevention and control teams need to identify surveillance activities that will meet their facility’spriorities and objectives. The traditional hospital-wide surveillance, where data were collected on everyinfection identified, has been largely replaced by targeted surveillance that focuses on specific HAIs,organisms, medical devices or high-risk populations.7

Jurisdictional surveillance allows aggregation of data from many HCFs, leading to a larger dataset withincreased statistical value. Statewide trends can be identified to inform priorities for statewide infectionprevention policies. Indicators selected for jurisdictional HAI surveillance are generally:*procedures that are high volume or high risk for infection and are associated with high morbidity andmortality e.g. hip and knee arthroplasty*medical device use in high-risk groups e.g. central venous catheters used in intensive care unit (ICU) patients*significant organisms associated with antibiotic resistance and high morbidity and mortality.5. Surveillance methodologyThe value of surveillance is enhanced by providing high quality comparative data. For participating hospitalsto make a valid comparison of their infection rates, the methodology used must be similar. HISWA aims forhigh sensitivity and specificity of reported HAIs. Sensitivity is based on false-negative HAIs i.e. true HAIs thatare not reported and specificity is based on false-positive HAIs i.e. reported infections that do not meet theHAI surveillance definitions.Processes are required to ensure that surveillance personnel automatically receive copies of all microbiologyreports, in real-time, for patients presenting to their facility, including outpatient and emergency presentations.HISWA requires surveillance personnel to implement active, prospective, patient-based surveillance.4The use of the flow charts provided in each indicator chapter is recommended to assist with each case review.5.1 Active, prospective case-finding***Active case-finding processes are required to identify patients who develop HAIs from the time of theiradmission until discharge, and on readmission with infection.All microbiological results relevant to a surveillance indicator should be investigated and interpreted inconjunction with information from clinical sources.Each case-finding method has some merit and limitations, therefore, in addition to the review of allrelevant laboratory reports, a combination of case-finding methods that can be applied to eligiblepatients should be applied that include: total chart review for clinical data i.e. medical records, wound management plan, temperature chart,diagnostic and imaging reports e.g. x-ray, bone scan, ultrasound, biopsy and medication chart(antibiotics) liaison with clinical staff and regular ward rounds use of patient management systems for admission histories formal notification from clinical staff e.g. infection notification forms administration and coding reports e.g. ICD-10-AM pharmacy dispensing reports medical referrals e.g. for microbiologist or infectious disease physician the use of infection control management software where available.45.2 Patient-based surveillance*Patient-based surveillance requires identification of all eligible patients for inclusion in the surveillanceindicator. For example, in a reporting period: all patients undergoing a specific surgery must be counted for SSIs8

all patients that have had a central line in situ in ICU must be counted for ICU central lineassociated bloodstream infection (CLABSI) surveillance.*Surveillance personnel are required to determine the optimal method for obtaining denominator datafor each surveillance indicator at their HCF. This may include the utilisation of: theatre management systems/theatre booking slips/coding reports medical records systems/business administration systems ward staff on wards relevant to the surveillance indicator the use of infection control management software where available.5.3 DefinitionsStandardised surveillance definitions are essential for successful data collection and analysis. The definitionsdeveloped by the National Healthcare Surveillance Network (NHSN) within the Centers for Disease Controland Prevention (CDC) in the United States of America are the most comprehensive and widely useddefinitions for HAI surveillance.4 Adoption of these definitions allows for benchmarking opportunitieswith large international datasets. Data collection for many of the HISWA indicators is based on the NHSNdefinitions in addition to those developed for the Australian Council for Healthcare Standards (ACHS).2To improve the inter-rater reliability of HAI classification, contributors should ensure:*surveillance personnel are trained in the use of surveillance definitions*surveillance personnel consistently apply methodology for data collection and application of definitions****infections are classified strictly according to the definition and only include HAI that fulfil the criteria inthe definitionliaison occurs with appropriate medical/surgical teams to assist in determining the source of theinfectioninvestigation of the patient’s hospitalisation history to identify the attributable HCFany queries or ambiguities in relation to the application of the surveillance definitions are referred tothe Healthcare Associated infection Unit (HAIU).6. Data validationAll HISWA contributors need to have internal validation processes in place to confirm the data they aresubmitting is reliable and valid. Surveillance personnel should ensure:******prior to submission of data, that the clinical, laboratory and other diagnostic information collectedmeets the criteria in the definition and communication has occurred with relevant stakeholders of all SSIs with a designated member of the surgical teamthey generate appropriate facility-specific reports to enable cross-checking of cases admitted forprocedures and with infections e.g. ICD-10-AM reportsthey use HISWA hospital level raw data report i.e. data entered in the HISWA database, to cross-checkwith internal records prior to submission.they use consolidated laboratory reports and cross-check to ensure all relevant cases have beeninvestigated.administrators providing bed-day data are informed of the data requirements outlined in Module 108.denominator data received from administrators and other external departments is cross-checked withdata from previous months to identify potential outliers.9

7. Data entry to HISWAPrior to utilising the HISWA database, contributors should familiarise themselves with the HISWAinformation for new contributors. A username and password is assigned to each hospital to allow loginto the database. Education and guidance on performing HISWA surveillance for new contributors can bearranged with members of the HAIU team by emailing contributors have access to the HISWA Database Manual to assist with the technical details of dataentry to the HISWA database. This can be accessed from the menu page of the database following login.All contributors need to ensure they:*enter data accurately into the HISWA database*save each record after data entry****use the Raw Data Report in the Reports module to check both numerator and denominator data priorto finalising datahave entered the HAIs in the appropriate modules when they meet the definition for multiple indicatorse.g. a methicillin-resistant Staphylococcus aureus bloodstream infection (MRSA BSI) needs to beentered in the Specific Organism module and the Specific Organism Bloodstream moduleuse the Finalisation Page as a means of checking data and advising HAIU that data submission iscompletefinalise data monthly for the previous month e.g. April data must be finalised by the last day of May.8. Data analysisData analysis is an essential component of the surveillance cycle so that HAIs can be described andcommunicated in a meaningful way.8.1 Calculation of ratesA rate indicates a relationship between two measurements with different units of measure and is used in HAIsurveillance to describe HAIs in patient populations of different sizes and in different time periods.A rate has three components:*numerator: the number of infections*denominator: the number of patients at risk*constant: a multiple of 10 that results in a number greater than zero.Mathematically, the rate is calculated as the numerator denominator x constant. Rates are generallyexpressed according to the denominator and the constant used e.g. per 100 surgical procedures or per1,000 central line days.8.2 The p-valueThe p-value determines the probability that the difference between two rates has arisen by chance. If theprobability is low ( 0.05 or 5%) then the difference in rates is considered to be unlikely due to chance aloneand therefore represents a significant difference.10

8.3 Confidence intervalsHISWA rates are calculated with 95 per cent confidence intervals (CI) which provides an indication of thetrue infection rate. The CI displays the lowest and highest values that the true infection rate is likely to fallbetween 95 per cent of the time. As a general rule, a larger sample size results in a narrower CI and thusgives a better indication of the true rate.8.4 Risk stratificationRisk stratification categorises patients at risk of infection into homogenous groups so that comparisons ofinfection rates can be made between groups with similar risk factors.2Examples of risk stratification used by HISWA include:****a risk index score for surg

1 Contents Foreword 2 Module 1 – Introduction to surveillance of healthcare-associated infections 4 Module 2 – Surgical site infection surveillance 13 Module 3 – Methicillin-resistant Staphylococcus aureus (MRSA) healthcare associated infection 30 Module 4 – Clostridioides difficile infection 43 Module 5 – Vancomycin-resistant enterococci (VRE) sterile site infection 52

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