HISWA Surveillance Manual

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Healthcare Infection Surveillance Western AustraliaHISWAHISWAHealthcare Infection Surveillance Western AustraliaSurveillance ManualVersion 6.1 May 2019

This publication has been produced by the Healthcare Associated Infection Unit,Communicable Disease Control Directorate. Department of Health, Western AustraliaMay 2019Contributors / EditorsPeterson A, McCann R, Tempone S.VersionDateDescription6.1May 2019Transferred toHealth templatecurrentDepartment ofContact DetailsHealthcare Associated Infection UnitCommunicable Disease Control DirectorateDepartment of Health Western AustraliaPO Box 8172Perth Business CentreWestern Australia 6849Telephone: 08 9388 4999Email: .wa.gov.au/2/37/3/healthcare associated infection unit.pm

ForewordHealthcare associated infections (HAIs) are one of the most common causes ofunintended harm suffered by health consumers. These infections cause the patientunnecessary pain and suffering and utilise significant human and financial resourceswithin healthcare systems. It is increasingly recognised that HAIs are preventableadverse events rather than an inevitable complication of medical care.Establishment of baseline HAI rates and ensuring ongoing monitoring is essential tomeasure the effectiveness of infection prevention strategies implemented to reducethe occurrence of HAIs.Both private and public healthcare facilities (HCFs) in Western Australia (WA)voluntarily commenced contributing data to the Healthcare Infection SurveillanceWA (HISWA) program in 2005. The introduction of mandatory indicators for allpublic HCFs and private HCFs contracted to provide care for public patientscommenced in 2007. Private HCFs continue to contribute data voluntarily. Theindicators collected for 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. Identify trends and engage clinicians to review clinical care to minimiseinfection risks and thus reduce the incidence of HAIs. Ensure activities are aligned, where possible, with Australian and internationalsurveillance programs to allow for relevant external benchmarking. Provide support to surveillance personnel contributing data to HISWA.This surveillance manual contains the technical information to allow standardiseddefinitions and methodology to be utilised by surveillance personnel reporting datato HISWA. HISWA data are analysed by staff at the Healthcare Associated InfectionUnit (HAIU), within the Department of Health WA. Aggregated data and detailedhospital specific reports are produced and distributed. All contributors areencouraged to internally review their own data to identify issues and trends in ai

timely manner. If any hospital requires assistance with their surveillance program,the HAIU team are available to provide support.ii

HISWA HAI ated infections due tomethicillin-resistant Staphylococcusaureus (MRSA)July 2005Surgical site infection following hip andknee arthroplastyJuly 2005Health-care associated bloodstreaminfection due to Staphylococcus aureus(methicillin-sensitive and MRSA)October 2007Healthcare associated Clostridiumdifficile infectionJanuary 2010Central line associated bloodstreaminfections in adult intensive care unitsJuly 2005Haemodialysis access-associatedbloodstream infection (AV fistula, AVgraft, non-cuffed and cuffed catheters)July 2005Healthcare worker occupationalJanuary 2008exposure to blood / body fluidsHISWA Non- Mandatory HAI IndicatorsCentral line associated bloodstreaminfections in Haematology/ Oncology.July 2005Surgical site infection followingcaesarean sectionApril 2011Requirements forData SubmissionAll data are requiredto be submittedwithin 30 days fromthe end of thereporting month.SSI following hip andknee arthroplasty issubject to a 90 daysurveillance period.Status(Mandatory StatusAssigned)Any private hospital can voluntarily submit data toHISWA where the indicator is relevant to their facilityMandatory(October 2007)Mandatory for all public metropolitan, regionalresource centres and integrated district hospitals.Mandatory(October 2007Mandatory for all public metropolitan, regionalresource centres and integrated district hospitalswhere arthroplasty procedures are performed.Mandatory(October 2007)Mandatory for all public metropolitan, regionalresource centres and integrated district hospitals.Mandatory(January 2010)Mandatory for all public metropolitan, regionalresource centres and integrated district hospitals.Mandatory(October 2009)Mandatory for all public hospitals with adult intensivecare units.Mandatory(July 2009)All data should besubject to internalvalidation processesprior to submission.CommentsMandatory(January 2008)Mandatory for all public metropolitan, regionalresource centres and integrated district hospitalswhere haemodialysis is performed.Mandatory for all public metropolitan, regionalresource centres and integrated district hospitals.VoluntaryparticipationAny private or public HCF where the indicator isrelevant to the provision of care.VoluntaryparticipationAny private or public HCF performing theseproceduresi

Table of ContentsModule 1Introduction to Surveillance1Module 2Surgical Site Infection (SSI)12 Hip and Knee Arthroplasty Caesarean SectionModule 3Significant Organism Methicillin-resistant Staphylococcus aureus (MRSA)infection32Module 4Significant Organism Clostridium difficile infection (CDI)45Module 5Significant Organism Vancomycin-Resistant Enterococci Sterile Site Infection55Module 6Specific Organism Bloodstream Infection Staphylococcus aureus bloodstream infection (SABSI)63Module 7Central Line-associated Bloodstream Infection (CLABSI) Adult intensive care unit Haematology Oncology75Module 8Haemodialysis Access-associated Bloodstream Infection93Module 9Occupational Exposure105Module 10HISWA Bed-days and Separations111TermsAbbreviations and Acronyms116i

List of Tables, Figures and AppendicesList of TablesTable 1HISWA indicatorsiTable 2Criteria for superficial incisional SSI16Table 3Criteria for deep incisional17Table 4Criteria for organ/space SSI18Table 5SSI numerator data fields and descriptors for HISWAdatabase21Table 6SSI denominator data fields for HISWA database23Table 7MRSA HAI numerator data fields and descriptors for HISWAdatabaseTable 840CDI numerator data fields and descriptors for HISWAdatabase49Table 9VRE sterile site infection numerator data fields and descrip60Table 10HA-SABSI numerator data fields and descriptors for HISWAdatabaseTable 11CLABSI numerator data fields and descriptors for HISWAdatabaseTable 1283Haemodialysis access-associated BSI numerator data fieldsand descriptors for HISWA databaseTable 137198Haemodialysis access-associated BSI denominator datafields for HISWA databaseTable 14Classification of HCW occupations and descriptorsTable 15Occupational exposure numerator data fields and98108descriptors for HISWA database109Table 16Monthly bed-day data required for HISWA113Table 17HISWA bed-day data fields114ii

List of FiguresFigure 1Essential components of the surveillance cycleFigure 2Schematic of SSI anatomy and classification15Figure 3Flowchart for surveillance of MRSA HAI34Figure 4Flowchart for determining a hospital identified CDI case47Figure 5Timeline for healthcare or community associated CDI definition53Figure 6Flowchart for surveillance of HA-SABSI65Figure 7Flowchart for surveillance of CLABSI79Figure 8Flowchart for surveillance of haemodialysis access associated BSI952List of AppendicesAppendix 1HISWA Operative Procedures27Appendix 2Specific Classification of an Organ/Space SSI28Appendix 3Risk Score Index Classification for SSI30Appendix 4Clarification of MRSA-Specific Antibiotic Therapy43Appendix 5MRSA SSI44Appendix 6VRE SSI62Appendix 7SABSI related to SSI74Appendix 8CLABSI – Definition of a Bloodstream Infection86Appendix 9CLABSI – Definition of a MBI-related BSI89Appendix 10 Examples relating to definition of neutropenia90Appendix 11 CLABSI – Sampling of ICU Central Line Days (workedexample)91Appendix 12 Haemodialysis Access-associated BSI – Definition of aBloodstream Infection101Appendix 13 HISWA Sample Denominator Data Collection Tool for SatelliteHaemodialysis Units104iii

Module 1Surveillance of Healthcare AssociatedInfections1

Surveillance of Healthcare Associated Infections1. Surveillance OverviewSurveillance is the systematic collection, management, analysis, interpretation andreporting of data for use in the planning, implementation and evaluation of theprovision of healthcare. The purpose of collecting and analysing surveillance data isto monitor and support improvement in the quality and safety of patient care within ahealthcare facility (HCF). Data should not be collected just for the purpose ofcollecting data – the data needs to be used to make change. Effective surveillancesystems are the drivers for change and make it possible to evaluate theeffectiveness of interventions. An effective surveillance system is one that providestimely feedback to HCF clinicians and managers to enable change to happen.1Figure 1 Essential components of the surveillance cycleDatacollectionIntervention /quality improvementData analysis &interpretationFeedback ofdata to keystakeholders2

2. Rationale for SurveillanceSurveillance of HAIs provides objective data on which to base decisions.Surveillance data allow the determination of whether a problem exists, identificationof the size of the problem and observation of trends over time. A sound surveillancesystem should help to: Determine baseline rates of HAI. Detect changes in rates or distribution of HAI. Facilitate investigation of significant increases in HAI rates. Assist in determining 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.23. Types of HAI Surveillance3.1 Outcome surveillanceOutcome surveillance involves measuring adverse healthcare events. Data may beexpressed as: Rates: time-series of HAI counts or proportions. Point prevalence: the proportion of patients with HAIs at the time of the survey. Incidence over time: the number of patients who develop a new HAI.33.2 Process surveillanceProcess surveillance involves auditing actual practice against evidence-basedinfection prevention strategies that are linked to improved outcomes e.g. auditing ofcompliance with surgical antibiotic prophylaxis. Improved processes should result inlower infection rates.33.3 Signal infection surveillanceSignal infection surveillance has been specifically developed to provide small andmedium sized HCFs with a framework to investigate HAIs using a root causeanalysis approach and to identify potential systemic issues requiring improvement.44. Selection of Surveillance Indicators In a HCF, infection prevention and control teams need to identify surveillanceactivities that will meet their facility’s priorities and objectives. The traditional3

hospital-wide surveillance, where data were collected on every infectionidentified, has been largely replaced by targeted surveillance that focuses onspecific HAIs, organisms, medical devices or high-risk populations. Jurisdictional surveillance allows aggregation of data from many HCFs, leadingto a larger dataset with increased statistical value. State-wide trends can beidentified to inform priorities for state infection prevention policies. Indicators selected for jurisdictional HAI surveillance are generally: procedures that are high volume or high risk for infection and areassociated with high morbidity and mortality e.g. hip and knee arthroplasty medical device use in high risk groups e.g. central venous catheters usedin intensive care unit (ICU) patients significant organisms associated with antibiotic resistance and highmorbidity and mortality.5. Surveillance MethodologyThe value of surveillance is enhanced by providing high quality comparative data.For participating hospitals to make a valid comparison of their infection rates, themethodology used must be similar. HISWA aims for high sensitivity and specificity ofreported HAIs. Sensitivity is based on false negative HAIs i.e. true HAI that are notreported and specificity is based on false positive HAIs i.e. reported infections thatdo not meet the HAI surveillance definitions.Processes are required to ensure that surveillance personnel automatically receivecopies of all microbiology reports, in real-time, for patients presenting to their facility,including outpatient and emergency presentations. HISWA requires surveillancepersonnel to implement active, prospective, patient-based surveillance.The use of the flow charts for each indicator is recommended to assist case review.5.1 Active, prospective case-finding Active case-finding processes are required to identify patients who developHAIs from the time of their admission until discharge, and on readmission withinfection.4

All microbiological results relevant to a surveillance indicator should beinvestigated and interpreted in conjunction with information from clinicalsources. Each case-finding method has some merit and limitations, therefore, in additionto the review of all relevant laboratory reports, a combination of case-findingmethods that can be applied to eligible patients should be in place that include: total chart review for clinical data i.e. medical records, woundmanagement plan, temperature chart, diagnostic and imaging reports e.g.x-ray, bone scan, ultrasound, biopsy and medication chart (antibiotics) liaison with ward or 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.5.2 Patient-based surveillance Patient-based surveillance requires identification of all eligible patients forinclusion in the surveillance indicator. For example, in a reporting period: all patients undergoing a specific surgery must be counted for SSIs all patients that have had a central line in situ in ICU must be counted forICU central line-associated bloodstream infection (CLABSI) surveillance. Surveillance personnel are required to determine the optimal method forobtaining denominator data for each surveillance indicator at their HCF. Thismay 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.5.3 DefinitionsStandardised surveillance definitions are essential for successful data collection andanalysis. The definitions developed by the National Healthcare Surveillance Network(NHSN) within the Centers for Disease Control and Prevention (CDC) in the UnitedStates of America are the most comprehensive and widely used definitions for HAIsurveillance. Adoption of these definitions allows for benchmarking opportunities5

with large international datasets. Data collection for many of the HISWA indicators isbased on the NHSN definitions in addition to those developed for the AustralianCouncil for Healthcare Standards (ACHS).To improve the inter-rater reliability of HAI classification, contributors should: Ensure surveillance personnel are trained in the use of surveillance definitions. Ensure surveillance personnel apply consistent methodology for data collectionand application of definitions. Classify infections strictly according to the definition and only include HAI thatfulfil the criteria in the definition. Liaise with appropriate medical / surgical teams to assist in determining thesource of the infection. Investigate the patient’s history to identify the attributable HCF. Refer any queries or ambiguities in relation to the application of thesurveillance definitions to the HAIU. Complete classification scenarios developed by the HAIU.6. Data ValidationAll HISWA contributors need to have internal validation processes in place to ensurethe data they are submitting is reliable and valid. Surveillance personnel should: Ensure, before submission of data, that the clinical, laboratory and otherdiagnostic information collected meets the criteria in the definition andcommunication has occurred with relevant stakeholders e.g. review of allsurgical site infections with a designated member of the surgical team. Generate appropriate facility-specific reports to enable cross checking of casesadmitted for procedures and with infections e.g. ICD-10-AM reports. Use HISWA hospital level raw data report i.e. data entered in the HISWAdatabase, to cross check with internal records prior to submission. Use consolidated laboratory reports and cross check to ensure all relevantcases have been investigated. Ensure administrators providing bed-day data are informed of the datarequirements outlined in Module 8. Cross check denominator data received from administrators and other externaldepartments with data from previous months to identify potential outliers.6

7. Data Entry to HISWAPrior to utilising the HISWA database, contributors should ideally meet with amember of the HAIU team for an introductory training session. A username andpassword is assigned to each hospital to allow login to the database.All contributors have access to the HISWA Database Manual to assist with thetechnical details of data entry to the HISWA database. This can be accessed fromthe 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 anddenominator data prior to finalising data. Ensure HAIs are entered in the appropriate modules when they meet thedefinition for multiple indicators e.g. a Methicillin–resistant Staphylococcusaureus (MRSA) bloodstream infection (BSI) needs to be entered in the SpecificOrganism module and the Specific Organism Bloodstream module. Use the Finalisation Page and finalise 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 canbe described and communicated in a meaningful way.8.1 Calculation of rates A rate indicates a relationship between two measurements with different unitsof measure and is used in HAI surveillance to describe HAIs in patientpopulations 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:(numerator denominator) x constant.7

Rates are generally expressed according to the denominator and the constantused e.g. per 100 surgical procedures or per 1000 central line days.8.2 The p value The p value determines the probability that the difference between two rateshas arisen by chance. If the probability is low ( 0.05 or 5%) then the difference in rates is consideredto be unlikely due to chance alone and therefore represents a significantdifference.8.2 Confidence intervals HISWA rates are calculated with 95% confidence intervals (CI) which providesan indication of the true infection rate. The CI displays the lowest and highest values that the true infection rate islikely to fall between 95% of the time. As a general rule, a larger sample size results in a narrower CI and thus givesa better indication of the true rate.8.3 Risk stratification Risk stratification categorises patien

Appendix 4 . Clarification of MRSA-Specific Antibiotic Therapy . 43 Appendix 5 . MRSA SSI . 44 Appendix 6 . VRE SSI . 62 Appendix 7 . SABSI related to SSI . 74 Appendix 8 . CLABSI – Definition of a Bloodstream Infection . 86 Appendix 9 . CLABSI – Definition of a MBI -related BSI . 89 Appendix 10 . Examples relating to definition of .

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