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Targeted Surveillance for Nosocomial InfectionsBarbara M.Soule,RN,MPA,CICChinese Society for Nosocomial InfectionsJuly 4-5,2004 Suzhou,China1Targeted Surveillance for NosoIC Practitioner(ICP)ActivitiesSurveillanceProgramManagementEducationMiscellaneousOutbreakInvestigationConsultation2IC Practitioner(ICP)ActivitiSurveillance has an Epidemiologic foundationStudy the distribution of problems and events within a defined (targeted)population at risk for developing specific infections in order to plan&implement interventions.3Surveillance has an Epidemiolo3 Key Surveillance Methods Hospital-wide Traditional SurveillanceAll infections complete-time consumingLimits time for interventions Periodic SurveillanceSelected infections or populations periodically over timeMiss some infections Targeted Surveillance43 Key Surveillance Methods HoAdvantages/DisadvantagesAdapted from Pottinger et al&Gaynes et al.5Advantages/DisadvantagesAdapteTargeted Surveillance6Targeted Surveillance6CDCs National Nosocomial Infections Surveillance(NNIS)System Targets:NNIS SystemAURICUHRNSurgicalPatientAntimicrobialUse and ResistanceIntensive CareUnit(Adult/Pediatric)High Risk Nursery(NICU)Risk adjustedSSIs byProcedures7CDCs National Nosocomial InfeYour Hospital Surveillance System Targets:Your HospitalVAPICUBSISSIVentilator-Associated PneumoniaMedical/Surgical ICUsIntensive CareUnit(Pediatric)Primary BloodStream InfectionsPrimary OrthopedicNeurosurgical or CABGProcedures8Your Hospital Surveillance SysWhich infection to target?Focus on patients at high risk for HAIPatient care areasICUs,cardio-thoracic surgery,cancer wardSpecific populationsneonates,transplant patients,hemodialysis ptsProcedures/DevicesCT surgery,central vascular lines,ventilatorsOrganisms of epidemiologic importance MRSA,VRSA9Which infection to target?FocTargeted Surveillance forOutcomesPrimary Bloodstream infectionsVentilator-associated pneumonia,Surgical site infectionsMRSA,VRE infectionsVascular access infections in hemodialysis patientsSharps injuries in healthcare providers.10Targeted Surveillance forOutcTargeted Surveillance for ProcessesHepatitis B immunity rates in personnelPersonnel compliance with protocols-isolation precautions,Sterilization quality assurance testing,Effective environmental cleaningAntimicrobial prescribing and administration11Targeted Surveillance for ProcHow to implement targeted surveillance12How to implement targeted survStep OneICP and MD review Microbiology reports dailyReview past surveillance data periodicallyDevelop a list of the potential infections or populations for targeted surveillance 13Step OneICP and MD review MicStep TwoInfection control team selects nosocomial infections to target based on one or more of the following criteria:14Step TwoInfection control teamCriteria for Selecting Processes or Outcomes for Targeted SurveillanceIC program objectivesFrequency or level of risk of infectious complications for areapatient population procedure service Morbidity,Mortality,CostPossibility for prevention15Criteria for Selecting ProcessStep ThreeICP performs chart reviews on the infection-related processes or outcomes identified in Step Two using standardized,consistent,approved definitions.Consistent intensity and thoroughness of surveillance over timeSame definitions over time 16Step ThreeICP performs chart Targeted Surveillance:A Means to an EndCollect only necessary data Arrive at meaningful information17Targeted Surveillance:A MeanSo You Can:Develop meaningful interventionsDO something to reduce infectionsImprove patient care!18So You Can:Develop meaningful The Cycle for Success Through Targeted Surveillance1.Is there an important problem?2.3.What,why?4.Multidisciplinary Teams 2.Describe and understand the problem?Targeted Surveillance 3.How to affect change?Multidisciplinary TeamsEducationFeedbackNew protocolsNew products4.Do the changes work?Remeasure Adapted from:Richards C,et al.Emerg Infect Dis 200119The Cycle for Success Through NLMIgnaz Semmelweis Targeted Surveillance And InterventionFor Puerperal Sepsis20NLMIgnaz Semmelweis20Targeted Surveillance for a ProcessTiming of Antibiotic Prophylaxis for Surgical Site InfectionNLM Archives21Targeted Surveillance for a Pr1.Is There an Important Problem?Inappropriate surgical prophylaxis is a major infection risk exposes patient to unnecessary toxicityincreases antimicrobial resistanceexcess doses or inappropriate spectrum antibiotics do not reduce the incidence of surgical wound infection221.Is There an Important Prob“Ideal”ProphylaxisIdeal antibiotic for prophylaxisactive against pathogens most likely to contaminate woundadequate concentrations during potential contaminationadministered for a short time to reduce complications,resistance,and cost23“Ideal”ProphylaxisIdeal antibTargeted Process SurveillanceTiming of Perioperative Antimicrobial ProphylaxisClassen DC,et al.The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.N Engl J Med 1992;326:281IncisionHours beforeincisionHours afterincisionAntibioticAdministered24Targeted Process SurveillanceTiming ofPerioperative Antimicrobial ProphylaxisClassen DC,et al.The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.N Engl J Med 1992;326:28125Timing ofPerioperative Antimi2.Perform Targeted Surveillance for This Problem1)Proportion of patients who receive prophylactic antibiotics within 1 hour before surgical incision#antibiotics 1 hour#surgeries with antibiotics262.Perform Targeted SurveillanPerform Targeted Surveillance for This Problem2)Proportion of patients whose antibiotics were discontinued within 24 hours of the surgery end time#discontinue w/I 24 hours#surgeries receiving antibiotics27Perform Targeted Surveillance Possible Surgical Procedures to Determine Timing of Antibiotic ProphylaxisCABGColon surgeryHip and knee arthroplastyAbdominal and vaginal hysterectomyVascular surgery(e.g.,peripheral vascular surgery)28Possible Surgical Procedures t3.To Affect ChangeMultidisciplinary Team to look at antibiotic delivery system:current and desiredRedesign system for timely AB deliveryMake antibiotic accessibleEducate nursing and operating room staff and anesthesiologists and surgeonsRecord time on patient chart293.To Affect ChangeMultidiscip4.Do the changes work?Re-measure 2 variables in 3 months after initiation of new improved procedureMeasure surgical site infection rates.304.Do the changes work?Re-measTargeted Surveillance for an InfectionOutcome31Targeted Surveillance for an ITargeted Surveillance for OutcomesNI Rate:VAPCR-BSIUTIFoley relatedNon-Foley related Drives Intervention For:Pneumonia preventionCR-BSI preventionFoley-care,d/c programPeri-care/hydration 32Targeted Surveillance for Outc1.Is There an Important Problem?Ventilator-associated pneumonia is a major infection risk for patientsincreased mortalityexcess length of stayexcess cost331.Is There an Important ProbExample:Challenge for Targeted SurveillanceReduce ventilator associated pneumonias(targeted adverse event)by 50%#VAP infections#1000 ventilator days34Example:Challenge for TargetReduction of VAP with Targeted Surveillance and InterventionsKwan KL,Baker SP,Fontecabio SA.Impact of a program ofintensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia,and its cost effectivenessICHE 2003;24;11:859-63.35Reduction of VAP with TargetedReduction of VAP with Targeted Surveillance and InterventionsInverventions:Raise head of bedSterile water for tube feedingsIn-line suction catheters from 24-48-72-as neededCost savings$350,000 in one year.36Reduction of VAP with Targeted1.Is There an Important Problem?Catheter-related bloodstream infections are a serious infection riskdevice-relatedmorbidity and mortalityextra length of stayadditional medical costs371.Is There an Important Prob0510152025JanAprilJulyOctJanAprilJulyOctJan989900SICU BSI Jan 98-MarchSICU BSI Jan 98-March 00Rate per 1,000 line daysRate per 1,000 line daysExample:Challenge for Targeted Surveillance380510152025JanAprilJulyOctJanAp2.Perform Targeted Surveillance for This Problem Monitor blood streaminfections in Surgical ICUpatients.392.Perform Targeted Surveillan3.Affect ChangeSuccessful interventions from targeted surveillance for BSI 1.Successful education program to reduce catheter associated blood stream infections2.Drapes and full PPE during insertion3.Monitoring and care for site 403.Affect ChangeSuccessful i4.Do the changes work?Re-measure in 3 months after initiation of new improved procedureMeasure bloodstream infection rates.414.Do the changes work?Re-meas0510152025JanAprilJulyOctJanAprilJulyOctJan989900SICU BSI Jan 98-MarchSICU BSI Jan 98-March 00BSIBSIInterventionInterventionsRate per 1,000 line daysRate per 1,000 line daysExample:Challenge for Targeted Surveillance420510152025JanAprilJulyOctJanApWith targeted surveillance43ImproveWith targeted surveilla
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