Infection Control Annual Report

2018
Success and Challenges in 2018
Way Forward in 2019
 HAI rates 2018
JAN FEB MARCH APRIL MAY JUNE JULY AUG SEP OCT NOV Dec
Total no of patients admitted in
that month
Total pts ventilated in that
month
TOTAL VENT DAYS
Total pts developed VAP
VAP %
Total pts inserted CL

Total CL days

Total pts developed CLABSI

CLABSI rate
Total pts inserted foley catheter
Total Foley catheter days

Total pts developed CA UTI

CAUTI rate
Total surgeries conducted in that
month
Total Clean & CC surgeries in
that month ( Elective)
Total pts developed SSI

SSI %
Total no of NSI in that month
Total HH moments observed
Total HH moments performed
Total No HCWs needed
vaccination
Total no of HCWs vaccinated
Total educational sessions
conducted
Total surveillance cultures
 HH details 2018
JAN FEB MARCH APRIL MAY JUNE JULY AUG SEP OCT NOV Dec
Total no of patients admitted in
that month

Total HH moments observed

Total no of HH moments
performed
Total no of HH moment1
observed
Total no of HH moment 1
performed
Total no of HH moment1 2
observed
Total no of HH moment 2
performed
Total no of HH moment 3
observed
Total no of HH moment 3
performed
Total no of HH moments 4
observed
Total no of HH moments 4
performed
Total no of HH moment 5
observed
Total no of HH moment 5
performed
Total no HH moments observed
for doctors
Total no HH performed by the
doctors
Total no of HH moments
observed for nurses
Total no of moments performed
by nurses
Total no of HH moments
observed for House keeping
staff
 Employees provided pre-exposure prophylaxis

INDICATORS MAR'1
JAN '18 FEB '18 Apr '18 May'18 Jun'18 Jul'18 Aug'18 Sep'18 Oct'18 Nov'18 Dec 18
8

Number of
employees
provided pre-
exposure
prophylaxis

Number of
employees who
were due to be
provided pre-
exposure
prophylaxis

Percentage of
Employees
provided pre-
exposure
prophylaxis
 SURGICAL ANTIBIOTIC PROPHYLAXIS
MONTH JAN FEB MARCH APRIL MAY JUNE JULY AUG SEP OCT NOV Dec

Total no of surgery conducted

Total no of emergency cases

Total no of clean & clean

contaminated elective cases

Total no received antibiotic

prophylaxis
To no received with in 1 hr before
incision

Total no received appropriate

antibiotics
Total stopped with 1 dose of
antibiotic

Total no stopped within 24 hours

Total No stopped within 48 hours

Total No surgery stopped after 48

hours

Total No of pts discharged with

antibiotics
 SURGICAL Patients followed in 2018
MONTH JAN FEB MARCH APRIL MAY JUNE JULY AUG SEP OCT NOV Dec
Total no of surgery conducted in
the last month
Total no of implant surgeries
conducted 2 months back
Total no of implant
surgeries conducted 3
months back
Total no of patients to be
followed for that one month
Total no of patients followed in
that month

Total no of patients followed by

phone
Total No of patients followed by
OP dressing registers

Total no patients came for OP

follow up

Total no of cases not followed in

that month
 MDRO 2018
JAN FEB MARCH APRIL MAY JUNE JULY AUG SEP OCT NOV Dec
Total no of culture specimens
receive by the lab
Total no of blood culture bottles
received by the lab
1 set blood culture ( aerobic +
anaerobic) received
2 sets blood culture received
Only 1 bottle culture received
More than 2 set blood culture
received
Total no of blood culture turned
positive

Total GNB positive

Total GPC positive

Total Mixed Growth
Total yeast growth

Total MDRO growth

MDRO percentage

Total urine culture received

Total positive urine culture

Total ET/ TT culture received

Total ET/ TT culture positive

Total no sputum received
Total +ve sputum culture
Total pus/ wound swab received

Total wound/pus culture +ve

Total no of fluids received
Total fluids positive
 Antibiotic utilization 2018
JAN FEB MARCH APRIL MAY JUNE JULY AUG SEP OCT NOV Dec

Total no of patients admitted in

that month

Total no of patients received IV

antibiotics

Total patients received oral

antibiotics

Total No of patients received

more than 1 antibiotic

Total no of patients discharged

in that month

Total no of patients discharged

with antibiotics

Most commonly used IV

antibiotic

Most commonly used oral

antibiotic
 ENVIRONMENTAL CULTURE
ENDOSCOPY RO RO WATER
MONTH RO WATER FROM OT WATER SETTLE PLATE CULTURE DIALYSIS FOOD ANALYSIS

JAN

FEB

MARCH

APRIL

MAY

JUNE

JULY

AUG

SEP

OCT

NOV
 NOTIFIABLE DISEASES
2018 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
ADME
ACUTE ENCEPHALITIS
SYNDROME
ACUTE FEBRILE
ILLNESS
ACUTE
GASTROENTIRITIS
AUREUS INFECTION
(MRSA)
CHICKEN POX
DENGUE FEVER
ENTERIC
FEVER/TYPHOID/SAL
MONELLA TYPH
H I V POSITIVE
H1 N1 DETECTED
HEPATITIS( VIRAL)
INFULUENZA A VIRUS
MENINGITIS
MENINGOENCEPHALIT
IS
PERITONEAL
TUBERCULOSIS
PERTUSSIS
COUGH
PYREXIA UNKNOWN
ORIGIN
SPASTIC
QUADRIPLEGIA
STATUS
EPILEPTICUS
SCRUB THYPUS
SEVERE PALLOR
TUBERCULOMA
 CLABSI-ORGANISM
ORGANISM

CLABSI ORGANISM

KLEBSIELLA
PNEUMONIAE KLEBSIELLA PNEUMONIAE
ENTEROCOCCUS FAECALIS
BURKHOLDERIA CEPACIAE

ENTEROCOCCUS
FAECALIS

BURKHOLDERIA
CEPACIAE
 VAP-ORGANISM
ORGANISM

CLABSI ORGANISM

KLEBSIELLA
PNEUMONIAE KLEBSIELLA PNEUMONIAE
ENTEROCOCCUS FAECALIS
BURKHOLDERIA CEPACIAE

ENTEROCOCCUS
FAECALIS

BURKHOLDERIA
CEPACIAE
 CA UTI-ORGANISM
ORGANISM

CLABSI ORGANISM

KLEBSIELLA
PNEUMONIAE KLEBSIELLA PNEUMONIAE
ENTEROCOCCUS FAECALIS
BURKHOLDERIA CEPACIAE

ENTEROCOCCUS
FAECALIS

BURKHOLDERIA
CEPACIAE
 SSI-ORGANISM
ORGANISM

SSI ORGANISM

PSEUDOMONAS
AERUGINOSA

PSEUDOMONAS
CLINICAL AERUGINOSA
CLINICAL

MRSA+PSEUDOMONAS
AERUGINOSA
MRSA+PSEUDOMONAS
AERUGINOSA ENTEROBACTER+ENTERC
OCCUS

ENTEROBACTER+ENTERC
OCCUS
 NSI-AREA
NSI
AREA NSI

OT

CATH LAB

OT
ER CATH LAB
ER
BMW STORAGE
PICU
BMW STORAGE ENDOSCOPY

PICU

ENDOSCOPY
 NSI-HCW

NSI
HCW NSI

DOCTOR

DOCTOR
NURSE
NURSE
HK
MAINTENANCE
HK

MAINTENANCE
What you consider your success in
2018 ?
What are the challenges you faced in
2018?
What is your focus in 2019 ?
What you expect from infectious
disease department?
 Infection Control Visit Calendar 2019

Internal Visit Areas Jan'19 Feb'19 Mar'19 Apr'19 May'19 June'19 July'19 Aug'19 Sep'19 Oct'19 Nov'19 Dec'19
CSSD

Dialysis

Endoscopy

Food & Beverages

H.K (Including
temporary storage)
Operation Rooms &
Cath Lab
ICUs Weekly once all the ICUs will be covered for IC audit. Daily visit for cultures and HAI Days.
Laboratory & Blood
Bank
Physiotherapy
Emergency Daily visit for Notifiable diseases and fever cases follow up . Audit once in a week
Ambulance
Burns Unit
Mortuary
External Visit Areas
BMW visit
Laundry visit