SURVEILLENCE INFECTION CONTROL

Dr. Elsye Maria Rosa, M.Kep

 PHLEBITIS

TAHAP-2
SURVEILLENCE PPI HAIS

INFEKSI SALURAN
KEMIH

INFEKSI DAERAH
TAHAP-1 OPERASI
HAND HYGIENE

INFEKSI ALIRAN DARAH

PRIMER

KEPATUHAN

VENTILATOR
ASSOCIATED
PNEUMONIA
KETEPATAN

MANAGEMENT OF
CHANGE
 What is a Surveillance System?
Surveillance is defined as the ongoing, systematic collection,
analysis, interpretation and evaluation of health data closely
integrated with the timely dissemination of these data to those
who need it.
There are two key aspects of surveillance systems:
1. Surveillance is an organized and ongoing component of a program
to improve a specific area of population health.
2. Surveillance systems go beyond the collection of information. They
involve mechanisms by which the knowledge gained through
surveillance is delivered to those who can use it to direct resources
where needed to improve health.
The surveillance system serves several
purposes,
1. Detection of disease outbreaks
2. Estimation of trends and development over time
3. Identification of population groups with special risks of
certain diseases, i.e. incidence according to age, gender, geography,
and personal characteristics in the form of for instance proceedings and
ethnicity
4. Estimation of impact of preventable measures such as
public information, prevention campaigns, and
vaccination programmes
5. Detection of changes in bacteria and virus, e.g. occurrence
of resistance towards antibiotics or certain pathogenic germs and - via this
- prioritization of prevention and control
6. Identification and solutions on research questions and
hypotheses on infectious diseases
 Essential Elements of Surveillance
A. Assess the population and identify those at greatest risk
1. Healthcare-associated infections (HAI) (outcomes)
2. Patient care practices aimed at preventing HAI (processes)
B. Select the outcome or process for surveillance
1. HAI, infection or colonization with a specific
2. Central line insertion practices (CLIPs), surgical care
medication errors,
influenza vaccination rates,
hepatitis B immunity rates,
personnel compliancee with protocols, etc.
C. Determine observation time period

D. Choose the surveillance methodology

E. Monitor for the outcome or process using standardized definitions for all data collected

F. Collect appropriate denominator data, if rates are to be calculated

G. Analyze surveillance data

H. Report and use surveillance information in a timely manner

Surveillance Methodology
B. Patient-based
A. Active and C. Prospective and
and laboratory-
passive retrospective
based
1. Active surveillance 1. Patient-based 1. Prospective surveillance
a) Trained personnel, mainly a) Count HAI a) Monitor patients during their
ICPs, vigorously look for HAI b) Requires ward rounds and hospitalization
b) Information accumulated) discussion with caregivers b) For SSIs, also monitor during
the post-discharge period

2. Passive surveillance 2. Laboratory-based 2. Retrospective

a) Persons who do not have a a) Detection is based solely on surveillance
primary surveillance role, the findings of laboratory studies a) Identify infections via chart
of clinical specimens reviews after patient discharge
D. Priority-directed and comprehensive

1. Priority-directed (also called targeted, focused, or Surveillance by Objective)

a) Objectives for surveillance are defined
b) Focus is on specific events, processes, organisms, and/or patient populations
2. Comprehensive
a) Continuous monitoring of all patients for all events and/or processes
b) Highly personnel resource intensive if done manually

E. Risk-adjusted rates and crude rates

1. Risk-adjusted rates
a) Rates are controlled for variations in the distribution of major risk factors associated with an
events occurrence
b) Such rates allow inter- and intra-facility rate comparisons
2. Crude rates
a) Rates assume equal distribution of risk factors for all events
b) Such rates cannot be used for inter-facility comparisons

F. Incidence and prevalence

1. Incidence
a) Count only new events occurring during some defined time period
2. Prevalence
a) Count all events (new and previously existing) occurring at either a point in time or during
some defined time period
ASSESS THE SENSITIVITY AND SPECIFICITY OF
SOURCES OF SURVEILLANCE DATA
a) Sensitivity of a case finding method describes its ability to correctly
include infections that are present (i.e., the number of true positive
infections detected by a case finding method divided by the number of
true positive infections + false negative infections detected by the case
finding method).

b) Specificity of a case finding method describes its ability to correctly

exclude infections that are not present (i.e., the number of true negative
infections detected by a case finding method divided by the number of
true negative infections + false positive infections detected by the case
finding method)
 15

SSI Surveillance
Requires
Consistent use of standard methods and definitions for
identifying procedures performed and SSI that result
Capture of sufficient risk factor data for each procedure
performed
Application of risk adjustment methods for meaningful
comparisons (i.e., over time within your hospital or to
national referent data)
 22

SSI Surveillance Period

Post-operative monitoring period determined by NHSN
Procedure Category
14 NHSN procedure types require 90-day monitoring period
BRST* CRAN HPRO RFUSN *Not a required
CA-reportable
CARD FUSN KPRO VSHN* procedure

CBGB FX PACE
CBGC HER PVBY*

All other procedure categories monitored for 30 days

regardless of presence of an implant
For all NHSN procedure categories, superficial SSI are
monitored for 30 days only
 23

NHSN SSI Surveillance Definition

Categorized
based on depth
of infection
 24

Superficial Incisional SSI

NHSN Surveillance Definition, 2015

Infection occurs within 30 days after surgical procedure

AND
Involves only skin and subcutaneous tissue of the incision
AND
At least 1 of 4 criteria:
1. Purulent drainage from the superficial incision
2. Organism isolated from incision culture or fluid (obtained
aseptically)
3. Diagnosis of superficial SSI by surgeon or attending physician
or other designee
4. Incision opened by surgeon At least 1 of the following:
AND Pain or tenderness
or designee; culture
Localized swelling
positive or not cultured Erythema
Heat

Do not report stitch abscess as an SSI (defined as minimal inflammation

and discharge confined to points of suture penetration). Do not report a
localized stab wound infection as an SSI. Cellulitis by itself is not an SSI
 25

Deep Incisional SSI

NHSN Surveillance Definition, 2015

Infection occurs within 30 after surgical procedure (UNLESS its one

of the 13 procedures followed for 90 days)
AND
Involves deep soft tissues of the incision, e.g. fascial & muscle layers
AND
At least 1 of 3 criteria:
1. Purulent drainage from deep incision
2. Abscess or evidence of infection involving deep incision detected
on gross anatomical or histopathologic exam or imaging test
3. Deep incision spontaneously dehisces
-OR- opened by surgeon, Patient has at least 1:
attending physician or designee fever>38C
AND localized pain, or
and is culture positive or not
cultured* tenderness
* A culture negative finding
does not meet this criteria
 26

Organ/Space SSI
NHSN Surveillance Definition, 2015

Infection occurs within 30 after surgical procedure (UNLESS its one

of the 13 procedures followed for 90 days)
AND

Involves any part of body deeper than the fascial/muscle layers, opened
or manipulated during the surgical procedure
AND

At least 1 of 3 criteria:
1. Purulent drainage from drain placed into organ/space
2. Organism isolated from an aseptically-obtained culture of
fluid or tissue in the organ/space
3. Abscess or evidence of infection involving the organ/space
that is detected on gross anatomical or by histopathologic or
imaging test
AND
Meets surveillance definition for a specific NHSN infection site

NHSN Patient Safety Manual: Chapter 9, Table 4

 28

Infection Present at Time of Surgery (PATOS)

Evidence of an infection present at the time of an index
surgery (i.e. present pre-operatively)
Required field when reporting an SSI event
Not required when reporting the procedure (i.e. not a
field on the denominator form)
Evidence of infection must be noted/documented in a
pre-operative or intra-operative note
 29

Infection PATOS -2

Only select PATOS=YES if it applies to the depth of the

SSI that is being attributed to the procedure

Examples:
If a patient had evidence of an intra-abdominal infection at the
time of surgery and then later returns with an organ space
SSI, the PATOS field would be selected as a YES.
If the patient returned with a superficial or deep incisional SSI,
the PATOS field would be selected as NO.
 30

Infection PATOS - 3
The patient does not have to meet the NHSN definition of
an SSI at the time of the primary procedure but there
must be notation that there is evidence of infection or
abscess present at the time of surgery
SSI reported with PATOS=YES will be excluded from the
SSI SIR
PATOS-related SSIs will be analyzed separately
Refer to the NHSN SSI Protocol for more examples
 31

SSI Following Multiple Procedures

If >1 operative procedure is done through a single incision
and an SSI occurs
First, attempt to determine the procedure associated
with the infection
If it is not clear, use the NHSN Principal Operative
Procedure Selection List to determine the priority
procedure for which to attribute the SSI
Example: For abdominal surgeries
- COLO is higher priority (higher infection risk) than SB
- SB is higher than REC
- REC is higher than GAST
Tahapan untuk Hand Hygiene dan
Surveillence HAIs
 Measurement: Outcome
Use NHSN Device-associated Module

http://www.cdc.gov/nhsn/library.html
 VENTILATOR-ASSOCIATED PNEUMONIA
BUNDLE OF CARE CHECKLIST

Patients Name PIN: ________________ Date of Admission: ____/____/____

Surname Given Name Middle Name Room No.:____________ Date Hooked on Ventilator:
Date of Birth: ____/____/____ Gender: Male ___/___/___
Female
mm dd yy
CHECKPOINTS
(To be performed every shift) Date: _____/______/_____ Date: _____/______/_____ Date: _____/______/_____
Is the patients head elevated by
AM PM N AM PM N AM PM N
3045 degrees?
Yes
No
Not assessed
Remarks:
Did the patient receive oral care
AM PM N AM PM N AM PM N
with Chlorhexidine?
Yes
No
Not assessed
Remarks:
Done by:
(Signature over Printed name)
CHECKPOINTS
(To be performed once a day)
Did the Physician evaluate
Yes No Not Yes No Not Yes No Not
whether the patient can be put off
done done done
from sedation?
Remarks:
Done by:
Does the patient have peptic Yes No Not Yes No Not Yes No Not
ulcer disease prophylaxis? done done done
Remarks:
Done by:
Does the patient have deep Yes No Not Yes No Not Yes No Not
venous thrombosis prophylaxis? done done done
Remarks:
Done by:
 Measurement: Surgical Care
Improvement Project (SCIP)
Process Measures
Quality Indicator Numerator Denominator
Appropriate antibiotic Number of patients who All patients for whom
choice received the appropriate prophylactic antibiotics
prophylactic antibiotic are indicated
Appropriate timing of Number of patients who All patients for whom
prophylactic antibiotics received the prophylactic antibiotics
prophylactic antibiotic are indicated
within 1hr prior to
incision (2hr:
Vancomycin or
Fluoroquinolones)
Appropriate Number of patients who All patients who
discontinuation of received prophylactic received prophylactic
antibiotics antibiotics and had them antibiotics
discontinued in 24 h
(48h cardiac)
Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP):
Evolution of National Quality Measures. Surg Infect 2008;9(6):579-84.
 Measurement: Outcome Measures
Risk Adjustment (2)
Standardized Incidence Ratio - SIR
SIR = Observed # SSI
Expected # SSI

Expected # SSI =
# operations* in each proc risk category X NNIS rate
100
Value >1.0 = more SSIs than expected
Helps better identify outliers
Will be used for comparison within NHSN in 2010
*Performed by a surgeon, a surgical subspecialty service or a hospital
Detailed explanation and examples in: Edwards JR, Horan TC. Risk-adjusted Comparisons.
In: Carrico R, ed. APIC Text of Infection Control and Epidemiology, 3rd ed. Washington DC
APIC 2009.Chapter 7, p.1-7.