LECTURE 1
WHY PERFORM SURVEILLANCE
IN LONG-TERM CARE
FACILITIES?
LECTURE OBJECTIVES
• To introduce concepts of surveillance
• To describe types of surveillance: prevalence
versus incidence
• To distinguish between colonisation and
infection
• To define Healthcare-associated Infection (HAI)
• To outline the HALT Point Prevalence Survey
(PPS)
• To provide results of HALT 2010 project
• To outline the lessons learnt from HALT 2010
SURVEILLANCE
What is surveillance?
• Systematic collection and analysis of
data and the use of this information for
action e.g.
– Improve care to patients/residents
– Reduce the occurrence of preventable
healthcare- associated infection (HAI)
– Compare with other facilities with same
resident mix
SURVEILLANCE
• Fundamental part of infection
prevention & control but requires
resources and skilled personnel
• 2 main types of surveillance used in
healthcare
1.Incidence
2.Prevalence
TYPES OF SURVEILLANCE
Incidence
• Provides ongoing data on all
organisms, infection sites and
wards
• Often used selectively on a
specific site of infection e.g.
– Surgical site surveillance
– Infections associated with central
venous catheters
TYPES OF SURVEILLANCE
Point Prevalence
•“Snap shot” at a specific point in
time e.g. one day
•The number of residents with the
‘condition of interest’ (e.g.
healthcare-associated infection)
divided by the total population at
a specific point in time
WHAT IS AN INFECTION?
• Signs and symptoms of an infection
varies depending on the site
• Common signs include:
– Pyrexia
– Inflammation
– Pain
– Presence of pus
– General malaise
COLONISATION IS NOT INFECTION
• Colonisation
– Microbes live on/in the body without any
ill effects e.g.
• S. aureus including MRSA in the nose or
on the skin
• E. coli (bowel)
• Includes microbes that are present in the
urine of long-term catheterised patients
but are not causing an infection
WHAT IS A HEALTHCARE –
ASSOCIATED INFECTION (HAI)?
An infection that someone
gets after being in hospital
or in contact with the
healthcare system e.g. being
in a long-term care facility
• ‘Healthcare-associated infection’(HAI) is
gradually replacing the terms ‘nosocomial
infection’ or ‘hospital-acquired infection’.
– In the past: most complex patient care
occurred in hospitals = where most of the
infections occurred.
– Now: patients treated in a variety of settings,
including long-term care facilities, primary
care etc.
WHAT IS THE HALT POINT PREVALENCE
SURVEY (PPS)?
HALT-2 PPS is looking at the prevalence of:
1. Healthcare-associated infection
2. Antimicrobial use
3. Antimicrobial resistance
4. Infection prevention and control resources
and practices
HOW IS PREVALENCE MEASURED?
PREVALENCE
(e.g. for antimicrobial use)
Total population of
Long-Term Care
Facility
Denominator:
Eligible residents
Numerator: Number of
residents on
antimicrobials
PREVALENCE
Numerator: Number of
residents on
antimicrobials
Denominator:
Eligible residents
Prevalence = 3 ÷ 9 = 0.33 x 100 = 33%
i.e 33% of residents are on antimicrobials
on the study day
3
9
EXAMPLES
Prevalence of Healthcare-associated
Infections (HAI)
Survey population: A
No. of patients with HAI on day of survey: B
Prevalence = B/A x 100 = C%
EXAMPLES
Prevalence of antimicrobial use
Survey population: A
No. of patients receiving antimicrobials on
day of survey: B
Prevalence = B/A x 100 = C%
HOW DO YOU MEASURE
INFECTION DURING
SURVEILLANCE?
• Standardised definitions
• Need specific number of signs/symptoms to
“fit” this definition
• NOT the same as clinical diagnosis
WHAT IS A HEALTHCAREASSOCIATED INFECTION (HAI)
FOR HALT-2?
An active healthcare-associated infection present on
the day of the survey is defined as follows:
“An infection is active when signs and symptoms of the
infection are present on the survey date or signs and
symptoms were present in the past and the resident is
(still) receiving treatment for that infection on the survey
date. The presence of symptoms and signs in the two
weeks (14 days) preceding the PPS day should be verified
in order to determine whether the treated infection
matches one of the case definitions of healthcareassociated infection.”
HALT HAI – IMPORTANT
CONSIDERATIONS - 1
• The onset of the symptoms should have
occurred 48h after the resident was admitted or
re-admitted to the LTCF (excluding infections
already present or in incubation at the time of
(re-)admission).
• Note: Surgical site infections should be excluded
from this study if the onset of the symptoms took
place within 30 days of the operation or within one
year in surgeries involving an implant. In these
situations, the surgical site infections are considered
as hospital-acquired.
HALT HAI – IMPORTANT
CONSIDERATIONS- 2
• All symptoms must be new or acutely
worse.
- Many residents have chronic symptoms, such
as cough or urinary urgency, that are not
associated with infection.
- However, a change in the resident’s status is
an important indication for infection in
development.
HALT HAI – IMPORTANT
CONSIDERATIONS-3
• Non-infectious causes of signs and symptoms
should always be considered before a diagnosis of
infection is made.
• Identification of infection should not be based on
a single piece of evidence. Microbiological and
radiological findings should be used only to
confirm clinical evidence of infection. Similarly,
physician diagnosis should be accompanied by
compatible signs and symptoms of infection.
EXAMPLE: URINARY TRACT INFECTION
Acute dysuria
Acute pain/swelling or tenderness of the testes,
epididymis, or prostate
Fever (> 38oC) or leukocytosis
 Acute costovertebral angle pain
 Suprapubic pain/tenderness
 Gross hematuria
 New or marked increase in frequency
 New or marked increase in urgency
 New or marked increase in incontinence
How many of these symptoms mean that a UTI is
present?
EXAMPLE: URINARY TRACT INFECTION
EXAMPLE: URINARY TRACT INFECTION
EXAMPLE: URINARY TRACT INFECTION
Exhaustive searching of signs/symptoms present in
residents is crucial in order to be able to confirm
infections.
WHY SHOULD A COUNTRY PERFORM
SURVEILLANCE IN ITS LONG-TERM
CARE FACILITIES?
• Growing demand for long-term care (LTC) due
to ageing population.
• The number of long-term care facility residents
that require complex care is also increasing.
• Residents of long-term care facilities play an
important role in the epidemiology of
antimicrobial resistant microorganisms.
• The frequency of infections is comparable to
that in acute care.
• Decline in length of stay in acute care
hospitals – individuals are being discharged
into the community earlier and presenting
with healthcare-associated infections (HAI).
• Accurate information on infections and
antimicrobial resistance and use is crucial to
increase awareness and to put strategies in
place to reduce preventable healthcareassociated infection and inappropriate
antimicrobial use.
WHY SHOULD MY LOCAL LONG-TERM
CARE FACILITY TAKE PART IN HALT -2?
…….lots of benefits!
• Get information on HAI, antimicrobial use and infection
control practices/resources.
• Benchmark against other long-term care facilities with
similar patient mix.
• Allows your long-term care facility to plan (based on
facts) improvements in patient care e.g. education/
development of policies/resources allocation.
• Study can be repeated to track improvements.
• Educates your staff on HAI, antimicrobial use &
surveillance.
WHAT DID WE FIND IN HALT-1 2010?
PARTICIPATING COUNTRIES
n° eligible
residents:
28 countries, 722 LTCFs
< 250
250 - 499
500 - 999
1000 - 4999
> 5000
Austria
Belgium
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Italy
Lithuania
Luxemburg
Malta
Poland
Portugal
Slovenia
Spain
Sweden
The Netherlands
UK:
England
Scotland
Wales
Total LTCF-beds:
67 613 beds
Northern Ireland
Mean LTCF size:
94 beds (9 – 695 beds)
Total eligible population: 63 884 r. (94.5%)
Katrien Latour ARHAI 2011
ANTIMICROBIAL USE
Crude prevalence: 4.3%
Mean prevalence: 4.9%
[Md: 3.4%, 95% CI 4.8% - 5.1%]
Katrien Latour ARHAI 2011
HEALTHCARE-ASSOCIATED INFECTIONS
Crude prevalence of
residents with HAI
(/100 ER)
0 - 0.99
1 - 2.99
3 - 4.99
5 - 6.99
According to modified McGeer
criteria
>7
Crude prevalence: 2.40%
Mean prevalence: 2.55%
[Md: 1.53%, 95% CI 2.43 – 2.67%]
Katrien Latour ARHAI 2011
LESSONS LEARNT FROM HALT-1
• Provided a baseline for many countries who
did this for the first time
• Raised awareness for Long-Term Care (less
resources & expertise)
• Use of data!
– Identify priorities for further research
– National and local initiatives
• Seasonal influence
Katrien Latour ARHAI 2011
WHY ARE WE REPEATING HALT?
• Increase the number of participating countries
and facilities
• Improve quality of data on HAI, antimicrobial
use and infection prevention and control
practices and resources
• Promote education, training and development
of guidelines
• Ultimately improve patient care