Surveillance of
HealthcareAssociated Infections
1. Explain the purpose or aims of surveillance.
2. Discuss how to establish a system for
healthcare-associated infection
surveillance.
3. Differentiate between continuous
surveillance and periodic prevalence
surveys.
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Learning Objectives
2
• 45 minutes
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Time involved
3
The systematic observation of the occurrence and
distribution of disease within a population and of
the events that increase or decrease the risk of the
disease occurrence
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What is Surveillance?
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 Identification of problems and prioritising
infection prevention and control (IP&C) activities
 Assisting the development of IP&C policies and
associated clinical practices
 Detecting changes in the endemicity of an HAI
or an adverse event
 Detecting changes in compliance with IP&C
policies
 Detecting outbreaks of adverse events
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Aims of HAI Surveillance - 1
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 Establishing the effectiveness of an
intervention
 Identifying whether the current program
meets benchmarks
 Establishing data for an evidence-based plan
to improve care and to meet accreditation or
regulatory requirements
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Aims of HAI Surveillance - 2
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Infection surveillance framework includes:
 Assessing the population
 Selecting the outcome or process for surveillance
 Using surveillance definitions
 Collecting surveillance data
 Calculating and analyzing surveillance rates
 Applying risk stratification
 Reporting and using surveillance information
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Establishing a Framework
for Surveillance
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Assessment should evaluate:
1.
2.
3.
4.
High risk populations
High volume procedures, interventions
High impact infections
High cost infections
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Assessment of the Population
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• Outcome Surveillance
• Decreasing risk and costs
• Identify gaps
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Outcome vs. Process
• Process Surveillance
• Identify care delivery issues
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 Is it necessary to survey the entire health care
facility or only focus on high-risk patient groups or
procedures or commonly performed procedures?
 Have rates increased in certain groups/procedures
/interventions?
 What is the most important IP&C-related process
that is likely to be associated with this rate?
 How will a standard, validated, and reproducible
definition of infection be applied?
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What to consider in establishing
a surveillance framework - 1
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 Should continuous surveillance or point
prevalence surveys be used?
 How will the data be collected, stored, retrieved,
summarized, and interpreted?
 How will results to clinicians be provided in a
timely manner?
 How will the information be used to continue to
lower infection rates?
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What to consider in establishing
a surveillance framework - 2
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 Continuous surveillance or periodic
prevalence surveys
 Alert-based surveillance
 Post-discharge surveillance
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Types of Surveillance
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 Undertaken prospectively
 Best way to establish trends and distribution
of HAI incidence
 Can be active, passive, or a combination of
both
 Active surveillance involves daily visits to
patient wards/care units to assess patients atrisk of HAI
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Continuous Surveillance - 1
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 Case finding using active and passive
surveillance by an IP&C practitioner increases
correct detection of HAIs
 Only incidence cases of HAI should be reported
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Continuous Surveillance - 2
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 A good substitute for continuous surveillance
 Performed on a single day or week
 Can show the magnitude of HAI, highlight
problems requiring more investigation, and
identify changing patterns of HAIs
 Can be used to target areas or services where
infection rates are suspected to be high
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Prevalence Surveys
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Prevalence Survey: Line listing
Month/quarter
Year
Resident/patient
Identifiers
Name
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Area: _______________________________________
HAI
HAI
(No=0/Yes=1)
Antibiotic
Bed Number
Type of HAI
Microorganism
Treatment
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 Monitor specific clinical conditions
 surgical site infections caused by Group A
Streptococcus
 meningococcal meningitis
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Alert-based Surveillance - 1
 Is a part of the ICP team daily work
 Aims to warn of early outbreaks and allow rapid
control procedures
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 Alert organism surveillance
 Continuous monitoring of specific microorganisms
identified by the microbiology laboratory
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Alert-based Surveillance - 2
 Simple and cheap, and can be automated in
computerised laboratories
 Can show trends of specific microorganisms in
different wards over time
 Allows the IP&C team to formulate preventive
actions
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 A method of identifying patients with a HAI
after leaving the facility
 Often used for surgical site infection (SSI)
detection
 Will identify more infections and therefore
yield a higher SSI rate
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Post-discharge Surveillance
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 A letter sent home with the patient to
complete and return
 A questionnaire to the patients’ medical
practitioner
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How to Conduct PostDischarge Surveillance
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 An infection occurring during the process of care
in a health-care facility which was not present or
incubating at the time of admission
 Includes infections acquired in the health-care
facility but appearing after discharge and also
occupational infections among health-care
workers
 A cut-off point 48 hours after admission is
typically used to distinguish between HAI and
community infections
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Definitions for HAI
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 Infection rates vary according to the definition
used
 Comparisons should only be made if the same
set of definitions is used and applied in exactly
the same manner
 More meaningful to use surveillance data from
same institution
 to measure trends
 to alert staff of increasing problems
 to monitor the effectiveness of interventions
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What are standards or
thresholds for HAI rates?
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Rates are calculated with a numerator (number
of persons with the infection) divided by a
denominator (number of persons at risk for the
infection)
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Surveillance Statistics: Rates
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Incidence rate (%)
No. of patients diagnosed with new HAI
during the surveillance period x 100
No. of patients at-risk of HAI
during the same period
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Incidence Rate
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• The number of cases of active HAI in a
defined patient population
• May be new cases or ones that developed
before the survey timeframe and are still
active
• Prevalence rate
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Prevalence Rate - 1
• the proportion of patients in the population who
have an active infection at the time of the survey
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Number of new and existing cases of specific
HAI during the specified survey period
x 100
Total number of patients surveyed for HAI
during the specified survey period
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Prevalence Rate - 2
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 Based on an accumulation of person-time units with a
statistically rare numerator (e.g., CLABSI)
 Convention is to multiply the proportion by 1,000 to be
expressed as per 1,000 patient/bed/catheter days
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Incidence Density Rates
Calculation of Incidence density
number of new specific HAI
during the surveillance reporting period
Person-time of susceptible patients
at risk during the same surveillance period
x 1000
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 Number of devices per number of patient-days
 A measure of the total patient-days in which a
high-risk device was used
 Can be used as a marker for risk of infection
 Calculate the utilisation ratios for each unit with
a denominator that reflects only those patients
at-risk
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Utilisation Ratio
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Urinary catheter utilisation ratio
= Total number of urinary catheter-days
Total number of patient-days
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Calculation of Utilisation Ratio
Central catheter utilisation ratio
= Total number of central catheter-days
Total number of patient-days
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Number device-associated infections for a site x 1,000
Number of device-days
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Device-Associated Infection
Rates
Infection rate per 1,000 device-days
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Number of catheter-associated UTI x 1000
Number of catheter-days
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Catheter-Associated
Urinary Tract Infection Rate
Infection rate of catheter-associated UTI
per 1000 catheter-days
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 Incidence data usually analysed periodically
to establish rates
 Typically calculated at the end of every
month or quarter
 Prevalence data analysed immediately at the
end of the survey to establish a rate that
reflects that survey period
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Frequency of Data Analysis
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 There should be a written surveillance plan for
the health care facility including
 definitions used
 how data are collected
 the frequency of data collection
 who is responsible for surveillance activities
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Summary - 1
 Surveillance activities should support a system
that can
 identify risk factors for infection and other adverse
events
 implement risk-reduction measures
 monitor the effectiveness of interventions
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 Surveillance plays a critical role in identifying
outbreaks, emerging infectious diseases,
antibiotic-resistance organisms, and bioterrorist
events so that infection prevention and control
measures can be instituted
 Surveillance program in healthcare organisations
should be integrated to include infection
prevention, performance improvement, patient
safety and public health activities
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Summary - 2
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• Lee TB, et al. Recommended practices for surveillance: Association
for Professionals in Infection Control and Epidemiology (APIC), Inc.
Am J Infect Control 2007; 35: 427-440.
• McLaws ML, Taylor P. The Hospital Infection Standardised
Surveillance (HISS) programme: analysis of a two-year pilot. J Hosp
Infect 2003; 53 (4): 260-268.
• Best Practices for Surveillance of Health Care-Associated Infections,
2008, Ontario Ministry of Health and Long-Term Care/Public Health
Division/Provincial Infectious Diseases Advisory Committee, Canada.
http://www.health.gov.on.ca/patient_safety/pro/cdad/toolkit_ricn/r
ep_pidac_hai_best_prac.pdf
• European Centre for Disease Prevention and Control. Surveillance
http://www.ecdc.europa.eu/en/activities/surveillance/Pages/Activiti
es_Surveillance.aspx
• VICNISS Hospital Acquired Infection Surveillance System. State
Government Victoria, Australia. http://www.vicniss.org.au/
December 1, 2013
References
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Epi Info, a free software package can be downloaded from
the Centers for Diseases Control and Prevention,
http://wwwn.cdc.gov/epiinfo/html/downloads.htm, with a
desktop calculator version accessed from
http://wwwn.cdc.gov/epiinfo/html/prevVersion.htm.
December 1, 2013
Epi Info
Alternatively, a free calculator written in Excel is available
at www.pedro.org.au/wp-content/uploads/CIcalculator.xls
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1. The purposes of establishing an HAI surveillance system
include which of the following?
a.
b.
c.
d.
Identification of HAI problems within an organization
Detecting outbreaks of HAIs
Establishing data for improving patient outcomes
All of the above
December 1, 2013
Quiz
2. Which of these types of surveillance can be used as a
substitute for continuous surveillance of HAIs?
a.
b.
c.
d.
Post discharge
Alert based
Prevalence
Prospective
3. A written surveillance plan is an important component of
the infection prevention and control programme. (T/F).
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• IFIC’s mission is to facilitate international networking in
order to improve the prevention and control of
healthcare associated infections worldwide. It is an
umbrella organisation of societies and associations of
healthcare professionals in infection control and related
fields across the globe .
• The goal of IFIC is to minimise the risk of infection within
healthcare settings through development of a network of
infection control organisations for communication,
consensus building, education and sharing expertise.
• For more information go to http://theific.org/
December 1, 2013
International Federation of
Infection Control
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