- Email: [email protected]
A profile of smaller hospitals: Planning for a novel, statewide surveillance program, Victoria, Australia
A profile of smaller hospitals: Planning for a novel, statewide surveillance program, Victoria, Australia Noleen J. Bennett, RN, MPH,a Ann L. Bull, PhD, BSc(hons), MApEpid,a David R. Dunt, PhD, MB, BS, FFPH,b Lyle C. Gurrin, PhD, BSc(hons),b Michael J. Richards, MD, MB, BS, FRACP,a Philip L. Russo, RN, MCE,a and Denis W. Spelman, MB, BS, MPH, FRACP, FRCPAc Melbourne, Australia
Victoria, the smallest state on the Australian mainland covers 227,010 square kilometers. It has a population of 4.9 million, of which 3.5 million live in the capital city of Melbourne.1 There are currently 90 public acute care hospitals within this state that may be classified as ‘‘smaller’’ (,100 beds) hospitals. In comparison, there are 28 ‘‘larger’’ (.100 beds) public acute care hospitals. A 1997 Department of Human Services (DHS) survey of these hospitals revealed that hospital-acquired infection surveillance was generally underdeveloped.2 As a result, in 2000, an expert working group was appointed that subsequently recommended the establishment of the Victorian Hospital-Acquired Infection Surveillance System (VICNISS) Coordinating Centre. The aim of this center is to develop, implement, support, and evaluate statewide surveillance programs that enable public acute care hospitals to benchmark their performance in reducing hospital-acquired infections. In 2002, the VICNISS Coordinating Centre established a surveillance program for the larger hospitals that targets adult intensive care units (ICU), high-risk nurseries (HRN), and surgical site infections (SSI). This program is based on the well-established US Centers
From the Victorian Nosocomial Infection Surveillance System (VICNISS) Coordinating Centre, Melbourne, Australiaa; the School of Population Health, The University of Melbourne, Melbourne, Australiab; and the Microbiology and Infectious Diseases Unit, Alfred Hospital, Melbourne, Australia.c The VICNISS Coordinating Centre is fully funded by the Victorian Department of Human Services. Reprint requests: Noleen Bennett, RN, MPH, Senior Infection Control consultant, Victorian Hospital Acquired Surveillance System Coordinating Centre, 10 Wreckyn St., North Melbourne 3061, VIC Australia. E-mail: [email protected]. Am J Infect Control 2006;34:170-5. 0196-6553/$32.00 Copyright ª 2006 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2005.05.011
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for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance (NNIS) system. The NNIS system, which for statistical reasons excludes hospitals with less than 100 acute care beds, has demonstrated up to a 30% reduction in infection rates.3 The VICNISS Coordinating Centre is also required to establish a surveillance program for the smaller hospitals. This is challenging in that relatively few studies examine hospital-acquired infections or associated surveillance programs in smaller hospitals.4-9 The purpose of this paper is to present a useful and comprehensive profile of the smaller hospitals to assist in the planning of this requirement.
METHODS Multiple sources were used to assemble data on smaller hospital geographic locations, bed numbers, services, resources such as infection control (IC) personnel and information technology and current hospital-acquired infection surveillance activities. The Accessibility/Remoteness Index of Australia (ARIA)10 was sourced to quantify the geographic accessibility or remoteness of the smaller hospitals. ARIA categorizes Australian populated towns into 5 groups– highly accessible, accessible, moderately accessible, remote, and very remote–according to road distance to major service centres. Acute, subacute, and mental health bed numbers were derived from the 2001/2002 DHS Victorian Admitted Episode Dataset (VAED) (Subacute beds service rehabilitation, palliative care, geriatric evaluation, and management and nursing home type patients). All public and private acute care hospitals are annually required to report admitted patient activity to the VAED. Aged care bed numbers were obtained from Commonwealth Aged Care Standards and Accreditation Agency Ltd reports.11 Data were also obtained from a ‘‘preplanning survey’’ that was distributed in March 2003 to IC personnel in the smaller eligible hospitals. This survey was
Bennett et al
adapted from a survey previously mailed out to IC personnel working in the 28 larger Victorian public hospitals. An additional survey was later forwarded to all 27 hospitals that indicated on the preplanning survey that they had a hemodialysis unit. On the preplanning survey, hospitals were asked to approximate numbers of procedures performed per year for 33 surgical groups. Twenty-six of these groups were based on those used in the US NNIS system.12 Procedures in the other 7 groups had a low surgical infection risk but were included because of expected high throughput. In accordance with the Australian Care Health Standards (ACHS) recommendations,13 at least 100 procedures per surgical group each year was chosen as a threshold level at which NNIS type SSI surveillance might be considered. The ACHS users manual for SSI surveillance recommends that ‘‘organisations that perform less than this number use alternative statistical analytical methods for their infection data.’’
Data analysis Data were entered into the statistical software Stata (Version 8.2) to study trends in acute care to total bed ratio and IC hours across acute care bed classifications. Means for the number of acute care beds, total beds, and acute care to total bed ratio were compared between hospitals that were and were not included in the preplanning survey. Evidence for a linear trend in outcome measures across the categories of covariates was assessed using the F statistic, which is a measure of how much of the variability in the outcome measure can be explained by the covariate.
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Table 1. Allocation of beds in Victorian smaller public acute care hospitals
Classification Acute care Same day beds Multiday beds Total same/multiday beds Subacute Total same/multiday beds Aged care Low-level (hostel) beds High level (nursing home) beds All categories
Bed numbers
No. of hospitals
Total
Mean
Range
90 90 90
248 1501 1749
2.8 16.7 19.4
0-25 0-82 0-107
63 (70%)
280
4.4
1-29
57 (63%) 81 (90%)
1563 2236
27.4 27.6
4-118 2-90
90
5828
64.8
12-257
Geographic location Eighty-four (93%) of the 90 smaller hospitals were located in 1 of the 5 Victorian rural health regions. The other 6 smaller hospitals were located in 1 of the 4 metropolitan regions. According to the ARIA, 37 (44%) of the smaller rural hospitals were ‘‘Highly accessible,’’ 33 (39%) ‘‘Accessible,’’ and 14 (17%) ‘‘Moderately accessible.’’ None of the smaller rural hospitals were classified as ‘‘Remote’’ or ‘‘Very remote.’’
Bed numbers Many of the 90 smaller hospitals had additional subacute and/or aged care beds (None had allocated mental health beds [Table 1]). The acute care to total bed type ratio increased with increasing number of acute care beds (Table 2); a test for trend based on the F statistics from linear regression generated a P value ,.001. For most hospitals (84%), acute care and aged care beds were co-located on the 1 site.
RESULTS In calculating the acute care bed numbers, 1 hospital (107 acute care beds) unexpectedly exceeded the ‘‘100 or less acute bed’’ inclusion criteria. Data from this hospital were included in the analysis. IC personnel representing 85 of the 90 eligible hospitals returned the preplanning survey. Twenty-one (25%) of the returned surveys were inaccurate in that the IC person had incorrectly completed the survey for their health service rather than for each individual hospital in which they were employed (Forty-seven of the 90 hospitals were amalgamated as part of 17 separate health services). These surveys were excluded from the preplanning survey data analysis, leading to an overall inclusion rate of 64 (71%) smaller hospitals. The response to the additional hemodialysis survey forwarded to the 27 smaller hospitals with outpatient hemodialysis units was 19 (70%).
Hospital services Critical care services. Fourteen (22%) hospitals had a high dependency unit, but only 1 hospital (2%) had an ICU. None (0%) of the hospitals had an HRN. Forty-nine (77%) hospitals had emergency services. Hemodialysis units. Of the 19 responding hemodialysis units, 17 were satellite centers of 4 larger metropolitan tertiary care centers. The number of patients currently receiving hemodialysis in these outpatient settings varied from 1 to 36 (mean, 5.8; median, 3). The average number of sessions booked for a patient per week was 3. Surgical activities. Forty-four (69%) hospitals indicated that they perform surgery. These hospitals ranged in acute care bed size from 5 to 107 beds (mean, 29.1; median, 19.5). In comparison, the 20 hospitals (31%) that indicated that they did not perform
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Table 2. Comparisons between acute care bed classifications* Median No. of no. of Acute care: hospitals Acute bed No. of acute total bed performing classification hospitals care beds ratio surgery 1-5 6-10 11-20 21-50 51-110 Total
17 13 13 12 9 64
3 8 16 27 65
0.13 0.19 0.38 0.35 0.54
No. of hospitals performing $100 procedures for $1 surgical groupy
2 (12%) 8 (62%) 13 12 9 44
0 2 2 5 9 18
(0) (0) (1) (3) (7) (11)
Type of current surveillance Mean IC activities (%) designated UTI SSI BSI MRO Pneumonia Other weekly hr 6.24 6.15 8.31 14.83 21.33
76 54 77 66 66 67
12 46 77 83 89 59
29 38 62 66 56 51
24 31 54 75 66 48
35 31 46 42 22 38
24 54 23 66 56 30
UTI, Urinary tract infection, SSI, surgical site infection; BSI, bloodstream infection; MRO, multidrug-resistant organism. *Eleven offsite aged care beds campuses were added to the closest affiliated campus. y In brackets, number of hospitals performing $100 procedures for $1 NNIS surgical group are listed.
surgery ranged in smaller acute care bed size from 1 from 9 beds (mean, 4.4; median, 4) (Table 2). Eighteen hospitals performed at least 100 procedures per year in 1 or more of 19 surgical groups. Eleven hospitals only, however, performed at least 100 procedures per year in 1 or more of the 12 NNIS surgical groups. Those hospitals with a greater proportion of acute care beds were more likely to perform at least 100 procedures for 1 or more (NNIS classified) surgical groups (Tables 2 and 3). Across the 19 surgical groups, the number of times hospitals performed greater than 100 procedures was 64, for a total of 13,512 operative procedures. For the 12 NNIS classified surgical groups only, this decreased to 28, for a total of 6187 procedures (Table 3). Pathology services. Twenty-three (36%) hospitals indicated that they have on-site pathology services. Fifty-seven (89%) of the hospitals’ IC persons indicated, however, that they received microbiology pathology results. Of these 57 hospitals, 24 (42%) and 21 (37%) hospitals noted the frequency as daily and monthly, respectively (Twelve hospitals were classified as either ‘‘Other’’ or ‘‘Missing’’ data). For most (83%), notification was via a hard copy format.
IC personnel Sixty-two (97%) of the hospitals had designated IC employment hours. This varied from 2 to 44 hours per week (mean, 10.6 hours; median, 8 hours). The average weekly hours worked increased with increasing number of acute care beds (Table 2); the corresponding F statistic for a linear trend generated a P value ,.001. Only 1 hospital employed a full-time (.38 hours per week) IC person. Fifty-seven IC persons worked across the 64 hospitals. Two hospitals had more than 1 IC person officially employed to share the designated hours. Forty-nine IC persons (86%) held a formal IC (certificate or higher) qualification.
Current surveillance activities Sixty-one (95%) of hospitals participated in hospitalacquired infection surveillance activities. For 50 of these hospitals, the estimated time spent on this surveillance per week varied from 0.5 to 8 hours (mean, 1.94 hours; median, 1 hour). The type of surveillance commonly undertaken was urinary tract infection (67%), SSI (59%), bloodstream infection (51%), multiresistant organisms (48%), pneumonia (38%), and/or other (30%) (Table 2). Uniform definitions were not described. Twenty-four (39%) hospitals used ACHS and 13 (21%) hospitals used CDC/NNIS definitions. Three (5%) hospitals used both ACHS and CDC/NNIS definitions.
Information technology Only 10 of the 61 hospitals participating in hospitalacquired infection surveillance activities used software specific for surveillance of infections. Fifty-eight (91%) of the computers used by IC personnel had Internet connectivity (For the other hospitals, 2 did not have Internet connectivity, whereas an answer for 4 was not recorded). Of these hospitals, 10 used a dial-up system, and 48 had continuous access. Nineteen (30%) hospital information systems communicated via a health level 7 interface (HL7 is a messaging protocol to link data systems and is used widely in Australian health care services). Seventeen (27%) hospitals replied ‘‘No,’’ 21 (33%) ‘‘Don’t know,’’ and 7 did not record an answer.
DISCUSSION Hospitals need to develop effective surveillance programs appropriate to their local patient demographics and priorities.14 This profile highlights data that influence the planning of a statewide, hospital-acquired infection surveillance program for the Victorian smaller public acute care hospitals–all located in nonremote areas. Some results are applicable to all the smaller
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Table 3. Hospitals and surgical procedure group numbers Annual estimates for the 44 hospitals performing surgery
Surgical procedure group NNIS classified surgical procedure groups Abdominal hysterectomy Appendectomy Cesarean section Cholecystectomy Gastric Head and neck Herniorrhaphy Hip prosthesis Knee prosthesis Open fracture reduction Prostatectomy Skin grafts Non-NNIS classified surgical procedure groups Carpal tunnels Dilation and curettage Tonsillectomy Tubal ligation Urology Varicose veins Vasectomy Total
1. No. hospitals performing surgical group
2. Total no. of procedures performed
3. No. of hospitals performed #100 procedures
4. No. of hospitals performed $100 procedures
5. Total no. of procedures performed for column 4 hospitals
32 29 30 29 4 5 34 15 15 10 12 24
854 855 1397 2008 452 695 2737 120 168 540 177 300
31 28 26 24 2 4 25 14 14 9 11 23
1 1 4 5 2 1 9 1 1 1 1 1
128 240 615 1018 435 695 1751 120 168 540 177 300
40 36 30 34 15 33 39 466
1605 4326 1702 1232 2483 1063 1381 24,095
38 21 26 30 8 31 37 402
2 15 4 4 7 2 2 64
240 3509 607 491 2003 247 228 13,512
hospitals. Some important differences, however, between larger and smaller hospitals and between smaller hospitals of different acute care bed size are also demonstrated. In the smallest hospitals, there was a greater proportion of aged care beds. It would therefore be appropriate, as has occurred in preexisting surveillance programs (Table 2), for these hospitals to focus primarily on different infections. Published methods for long-term care facilities suggest monitoring commonly acquired respiratory tract, urinary tract, eye, ear, nose, mouth, skin, gastrointestinal, and systemic infections.15 The larger hospital ICU and HRN surveillance modules that target critically ill patients are not applicable to the smaller hospitals. In a recent US study, 57.9% of small rural hospital respondents had an ICU.4 In this profile, however, such critical care units were nearly nonexistent. It appears that, although invasive procedures may be initiated in the Victorian smaller hospitals, critically ill patients are usually transferred to accessible larger hospitals. Chronic hemodialysis patients are susceptible to infections and are an important population for inclusion in hospital-acquired infection surveillance programs.
The CDC currently has a national outcome-based surveillance program to monitor these infections.16 A similar program could be undertaken in Victoria; however, in the 109 CDC participating centers, the median number of patients treated each month was 56 (range, 7-284), compared with a median of 3 in the profiled smaller hospitals. The small sample size and correspondingly small number of incidents would probably limit meaningful analysis of any results. The majority of the smaller hospitals are ineligible to participate in the larger hospital SSI surveillance module (This result is consistent with Table 2, which highlights that the percentage of hospitals participating in preexisting SSI surveillance programs increased with an increasing number of acute care beds). For the smallest hospitals, this is primarily because they did not perform surgery. The other smaller hospitals performed limited numbers of procedures within the NNIS surgical groups and/or performed mostly procedures within the low infection risk surgical groups. Knowledgeable qualified personnel should manage the process of collecting surveillance data.14 This profile indicates an encouragingly high level of formal qualifications held by IC personnel–an improvement on previous related Australian studies17,18 and most
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likely a consequence of additional DHS funding made available in late 1999 to Victorian hospitals to improve IC outcomes. It, however, is unknown whether these qualifications include epidemiology as a key subject. Epidemiologic principles form the foundation of effective surveillance programs and therefore should be included in related education plans. No recommendations currently exist about the amount of time that IC persons should allocate to a surveillance program. This profile emphasizes, however, that the smaller hospital surveillance program has to be time efficient. Although almost all of the hospitals had at least 1 IC person employed, the designated variable IC hours were limited. In addition to this, as it has been highlighted elsewhere, many smaller hospital IC persons have other important responsibilities such as clinical care, occupational health and safety, and wound management.4,18 Across Victoria, the data show that 14% of total acute care bed days for smaller hospitals were ‘‘same day’’ admissions. This combined with the emphasis for decreasing the average length of ‘‘multiday’’ admissions highlights the need for postdischarge surveillance to be established if the magnitude of hospital-acquired infections is to be thoroughly documented. The best method to accomplish this, however, remains unclear.14 To achieve the aim of benchmarking data, the use of uniform case definitions would need to be implemented. In addition, a variety of sources would need to be consistently used to complete and confirm required surveillance datasets.14 From a previous DHS Victorian hospital survey, many acute care health services conducted laboratory-based surveillance combined with clinical ward rounds to identify infections.19 This profile suggests that the timely use of this case finding method may be impeded because of the absence of on-site pathology services and infrequent reporting in smaller hospitals. Computerization of surveillance systems can facilitate the functioning of the surveillance process. The acquisition, analysis, and exchange of information can be more proficiently provided.14 It is noted that the smaller hospitals in this profile would require further advancement in information management technology to obtain fully these potential benefits. The methodology used for this paper was subject to certain limitations. First, definitions and methodology to be used by the IC personnel for collecting the preplanning survey data were not detailed. Second, the small number of hospitals that did not participate in the preplanning survey had on average a lower number of acute care beds, total beds, and acute care to total bed ratio. A comparison of means for these variables with the corresponding means for the participating hospitals did not, however, provide strong evidence
that these characteristics influenced the tendency for hospitals to respond correctly to the survey. Despite these limitations, the data collected provide a useful and comprehensive profile to assist in the planning of a hospital-acquired infection surveillance program for Victorian, public, acute care, smaller hospitals. The program needs to be quite different to that developed for the larger hospitals and for smaller hospitals of significantly different acute care bed size. There are notable influential differences between these hospitals in local patient demographics and priorities. The authors thank the Clinical Governance Unit, Office of Chief Clinical Advisor, Department of Human Services and Melbourne Health; the IC personnel in the participating hospitals; VICNISS staff; and Graeme Steele and Stephen Gow at the Department of Human Services, who assisted with data collection.
References 1. Australian Bureau of Statistics 2003. Available from: www.abs.gov.au. Accessed April 27, 2005. 2. Department of Human Services. Infection control in Victorian public hospitals 1998 Available from: www.health.vic.gov.au. Accessed April 27, 2005. 3. Centers for Disease Control and Prevention. Monitoring hospital acquired infections to promote patient safety–United States 19901999. MMWR 2000;49:149-53. 4. Stevenson KB, Murphy CL, Samore MH, Hannah EL, Moore JW, Barbera J, et al. Assessing the status of infection control programs in small rural hospitals in the western United States. Am J Infect Control 2004; 32:255-61. 5. Scheckler WE. Hospital epidemiology and infection control in small hospitals. In: Mayhall CG, editor. Hospital epidemiology and infection control. Philadelphia: Lippincott Williams and Wilkins; 1999. p. 1455-9. 6. Scheckler WE, Peterson PJ. Nosocomial infection: prevalence, risk and control in small community and rural hospitals. Infect Control 1986;7: 144-8. 7. Scheckler WE, Peterson PJ. Nosocomial infections in 15 rural Wisconsin hospitals: results and conclusions from 6 months of comprehensive surveillance. Infect Control 1986;7:397-402. 8. Britt MR, Burke JP, Nordquist AG, Wilfert JN, Smith CB. Infection control in small hospitals: prevalence surveys in 18 institutions. JAMA 1976;236:1700-3. 9. Britt MR. Infectious diseases in small hospitals: prevalence of infections and adequacy of microbiology services. Ann Intern Med 1978;89: 757-60. 10. Australian Government Department of Health and Aging. Accessibility/ Remoteness Index of Australia (ARIA) Available from: www.health. gov.au. Accessed April 27, 2005. 11. The Aged Care Standards and Accreditation Agency Ltd. Available from: www.accreditation.aust.com. Accessed April 27, 2005. 12. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance System. NNIS System Report, Data summary from January 1992 to June 2002, Issued August. Atlanta, GA; 2002. 13. Australian Council of Healthcare Standards. Infection Control Indicators Version 2. NSW, 2003. Available from: www.achs.org.au. Accessed April 27, 2005. 14. Gaynes RP, Horan TC. Surveillance of nosocomial infections. In: Mayhall GC, editor. Hospital epidemiology and infection control. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 1285-316. 15. McGeer A, Campbell B, Emori TG, Hierhoizer WJ, Jackson MM, Nicolle LE, et al. Definitions of infection for surveillance in long term care facilities. Am J Infect Control 1991;19:1-7.
Bennett et al 16. Tokars JI, Miller ER, Stein G. New national surveillance system for hemodialysis-associated infections: initial results. Am J Infect Control 2002;30(5):288-95. 17. Cadwallader H, Nikoletti S. Current Australian nosocomial infection surveillance activities: a survey of Australian Infection Control Association (AICA) members. Australian Infect Control 2001;1:7-17.
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18. Murphy CL, McLaws ML. Who coordinates infection control programs in Australia? Am J Infect Cotrol 1999;27: 291-5. 19. Department of Human Services. Infection control in Victorian public health services 2002-2003. Available from: www.health.vic.gov.au. Accessed April 27, 2005.
Victoria, the smallest state on the Australian mainland covers 227,010 square kilometers. It has a population of 4.9 million, of which 3.5 million live in the capital city of Melbourne.1 There are currently 90 public acute care hospitals within this state that may be classified as ‘‘smaller’’ (,100 beds) hospitals. In comparison, there are 28 ‘‘larger’’ (.100 beds) public acute care hospitals. A 1997 Department of Human Services (DHS) survey of these hospitals revealed that hospital-acquired infection surveillance was generally underdeveloped.2 As a result, in 2000, an expert working group was appointed that subsequently recommended the establishment of the Victorian Hospital-Acquired Infection Surveillance System (VICNISS) Coordinating Centre. The aim of this center is to develop, implement, support, and evaluate statewide surveillance programs that enable public acute care hospitals to benchmark their performance in reducing hospital-acquired infections. In 2002, the VICNISS Coordinating Centre established a surveillance program for the larger hospitals that targets adult intensive care units (ICU), high-risk nurseries (HRN), and surgical site infections (SSI). This program is based on the well-established US Centers
From the Victorian Nosocomial Infection Surveillance System (VICNISS) Coordinating Centre, Melbourne, Australiaa; the School of Population Health, The University of Melbourne, Melbourne, Australiab; and the Microbiology and Infectious Diseases Unit, Alfred Hospital, Melbourne, Australia.c The VICNISS Coordinating Centre is fully funded by the Victorian Department of Human Services. Reprint requests: Noleen Bennett, RN, MPH, Senior Infection Control consultant, Victorian Hospital Acquired Surveillance System Coordinating Centre, 10 Wreckyn St., North Melbourne 3061, VIC Australia. E-mail: [email protected]. Am J Infect Control 2006;34:170-5. 0196-6553/$32.00 Copyright ª 2006 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2005.05.011
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for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance (NNIS) system. The NNIS system, which for statistical reasons excludes hospitals with less than 100 acute care beds, has demonstrated up to a 30% reduction in infection rates.3 The VICNISS Coordinating Centre is also required to establish a surveillance program for the smaller hospitals. This is challenging in that relatively few studies examine hospital-acquired infections or associated surveillance programs in smaller hospitals.4-9 The purpose of this paper is to present a useful and comprehensive profile of the smaller hospitals to assist in the planning of this requirement.
METHODS Multiple sources were used to assemble data on smaller hospital geographic locations, bed numbers, services, resources such as infection control (IC) personnel and information technology and current hospital-acquired infection surveillance activities. The Accessibility/Remoteness Index of Australia (ARIA)10 was sourced to quantify the geographic accessibility or remoteness of the smaller hospitals. ARIA categorizes Australian populated towns into 5 groups– highly accessible, accessible, moderately accessible, remote, and very remote–according to road distance to major service centres. Acute, subacute, and mental health bed numbers were derived from the 2001/2002 DHS Victorian Admitted Episode Dataset (VAED) (Subacute beds service rehabilitation, palliative care, geriatric evaluation, and management and nursing home type patients). All public and private acute care hospitals are annually required to report admitted patient activity to the VAED. Aged care bed numbers were obtained from Commonwealth Aged Care Standards and Accreditation Agency Ltd reports.11 Data were also obtained from a ‘‘preplanning survey’’ that was distributed in March 2003 to IC personnel in the smaller eligible hospitals. This survey was
Bennett et al
adapted from a survey previously mailed out to IC personnel working in the 28 larger Victorian public hospitals. An additional survey was later forwarded to all 27 hospitals that indicated on the preplanning survey that they had a hemodialysis unit. On the preplanning survey, hospitals were asked to approximate numbers of procedures performed per year for 33 surgical groups. Twenty-six of these groups were based on those used in the US NNIS system.12 Procedures in the other 7 groups had a low surgical infection risk but were included because of expected high throughput. In accordance with the Australian Care Health Standards (ACHS) recommendations,13 at least 100 procedures per surgical group each year was chosen as a threshold level at which NNIS type SSI surveillance might be considered. The ACHS users manual for SSI surveillance recommends that ‘‘organisations that perform less than this number use alternative statistical analytical methods for their infection data.’’
Data analysis Data were entered into the statistical software Stata (Version 8.2) to study trends in acute care to total bed ratio and IC hours across acute care bed classifications. Means for the number of acute care beds, total beds, and acute care to total bed ratio were compared between hospitals that were and were not included in the preplanning survey. Evidence for a linear trend in outcome measures across the categories of covariates was assessed using the F statistic, which is a measure of how much of the variability in the outcome measure can be explained by the covariate.
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Table 1. Allocation of beds in Victorian smaller public acute care hospitals
Classification Acute care Same day beds Multiday beds Total same/multiday beds Subacute Total same/multiday beds Aged care Low-level (hostel) beds High level (nursing home) beds All categories
Bed numbers
No. of hospitals
Total
Mean
Range
90 90 90
248 1501 1749
2.8 16.7 19.4
0-25 0-82 0-107
63 (70%)
280
4.4
1-29
57 (63%) 81 (90%)
1563 2236
27.4 27.6
4-118 2-90
90
5828
64.8
12-257
Geographic location Eighty-four (93%) of the 90 smaller hospitals were located in 1 of the 5 Victorian rural health regions. The other 6 smaller hospitals were located in 1 of the 4 metropolitan regions. According to the ARIA, 37 (44%) of the smaller rural hospitals were ‘‘Highly accessible,’’ 33 (39%) ‘‘Accessible,’’ and 14 (17%) ‘‘Moderately accessible.’’ None of the smaller rural hospitals were classified as ‘‘Remote’’ or ‘‘Very remote.’’
Bed numbers Many of the 90 smaller hospitals had additional subacute and/or aged care beds (None had allocated mental health beds [Table 1]). The acute care to total bed type ratio increased with increasing number of acute care beds (Table 2); a test for trend based on the F statistics from linear regression generated a P value ,.001. For most hospitals (84%), acute care and aged care beds were co-located on the 1 site.
RESULTS In calculating the acute care bed numbers, 1 hospital (107 acute care beds) unexpectedly exceeded the ‘‘100 or less acute bed’’ inclusion criteria. Data from this hospital were included in the analysis. IC personnel representing 85 of the 90 eligible hospitals returned the preplanning survey. Twenty-one (25%) of the returned surveys were inaccurate in that the IC person had incorrectly completed the survey for their health service rather than for each individual hospital in which they were employed (Forty-seven of the 90 hospitals were amalgamated as part of 17 separate health services). These surveys were excluded from the preplanning survey data analysis, leading to an overall inclusion rate of 64 (71%) smaller hospitals. The response to the additional hemodialysis survey forwarded to the 27 smaller hospitals with outpatient hemodialysis units was 19 (70%).
Hospital services Critical care services. Fourteen (22%) hospitals had a high dependency unit, but only 1 hospital (2%) had an ICU. None (0%) of the hospitals had an HRN. Forty-nine (77%) hospitals had emergency services. Hemodialysis units. Of the 19 responding hemodialysis units, 17 were satellite centers of 4 larger metropolitan tertiary care centers. The number of patients currently receiving hemodialysis in these outpatient settings varied from 1 to 36 (mean, 5.8; median, 3). The average number of sessions booked for a patient per week was 3. Surgical activities. Forty-four (69%) hospitals indicated that they perform surgery. These hospitals ranged in acute care bed size from 5 to 107 beds (mean, 29.1; median, 19.5). In comparison, the 20 hospitals (31%) that indicated that they did not perform
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Table 2. Comparisons between acute care bed classifications* Median No. of no. of Acute care: hospitals Acute bed No. of acute total bed performing classification hospitals care beds ratio surgery 1-5 6-10 11-20 21-50 51-110 Total
17 13 13 12 9 64
3 8 16 27 65
0.13 0.19 0.38 0.35 0.54
No. of hospitals performing $100 procedures for $1 surgical groupy
2 (12%) 8 (62%) 13 12 9 44
0 2 2 5 9 18
(0) (0) (1) (3) (7) (11)
Type of current surveillance Mean IC activities (%) designated UTI SSI BSI MRO Pneumonia Other weekly hr 6.24 6.15 8.31 14.83 21.33
76 54 77 66 66 67
12 46 77 83 89 59
29 38 62 66 56 51
24 31 54 75 66 48
35 31 46 42 22 38
24 54 23 66 56 30
UTI, Urinary tract infection, SSI, surgical site infection; BSI, bloodstream infection; MRO, multidrug-resistant organism. *Eleven offsite aged care beds campuses were added to the closest affiliated campus. y In brackets, number of hospitals performing $100 procedures for $1 NNIS surgical group are listed.
surgery ranged in smaller acute care bed size from 1 from 9 beds (mean, 4.4; median, 4) (Table 2). Eighteen hospitals performed at least 100 procedures per year in 1 or more of 19 surgical groups. Eleven hospitals only, however, performed at least 100 procedures per year in 1 or more of the 12 NNIS surgical groups. Those hospitals with a greater proportion of acute care beds were more likely to perform at least 100 procedures for 1 or more (NNIS classified) surgical groups (Tables 2 and 3). Across the 19 surgical groups, the number of times hospitals performed greater than 100 procedures was 64, for a total of 13,512 operative procedures. For the 12 NNIS classified surgical groups only, this decreased to 28, for a total of 6187 procedures (Table 3). Pathology services. Twenty-three (36%) hospitals indicated that they have on-site pathology services. Fifty-seven (89%) of the hospitals’ IC persons indicated, however, that they received microbiology pathology results. Of these 57 hospitals, 24 (42%) and 21 (37%) hospitals noted the frequency as daily and monthly, respectively (Twelve hospitals were classified as either ‘‘Other’’ or ‘‘Missing’’ data). For most (83%), notification was via a hard copy format.
IC personnel Sixty-two (97%) of the hospitals had designated IC employment hours. This varied from 2 to 44 hours per week (mean, 10.6 hours; median, 8 hours). The average weekly hours worked increased with increasing number of acute care beds (Table 2); the corresponding F statistic for a linear trend generated a P value ,.001. Only 1 hospital employed a full-time (.38 hours per week) IC person. Fifty-seven IC persons worked across the 64 hospitals. Two hospitals had more than 1 IC person officially employed to share the designated hours. Forty-nine IC persons (86%) held a formal IC (certificate or higher) qualification.
Current surveillance activities Sixty-one (95%) of hospitals participated in hospitalacquired infection surveillance activities. For 50 of these hospitals, the estimated time spent on this surveillance per week varied from 0.5 to 8 hours (mean, 1.94 hours; median, 1 hour). The type of surveillance commonly undertaken was urinary tract infection (67%), SSI (59%), bloodstream infection (51%), multiresistant organisms (48%), pneumonia (38%), and/or other (30%) (Table 2). Uniform definitions were not described. Twenty-four (39%) hospitals used ACHS and 13 (21%) hospitals used CDC/NNIS definitions. Three (5%) hospitals used both ACHS and CDC/NNIS definitions.
Information technology Only 10 of the 61 hospitals participating in hospitalacquired infection surveillance activities used software specific for surveillance of infections. Fifty-eight (91%) of the computers used by IC personnel had Internet connectivity (For the other hospitals, 2 did not have Internet connectivity, whereas an answer for 4 was not recorded). Of these hospitals, 10 used a dial-up system, and 48 had continuous access. Nineteen (30%) hospital information systems communicated via a health level 7 interface (HL7 is a messaging protocol to link data systems and is used widely in Australian health care services). Seventeen (27%) hospitals replied ‘‘No,’’ 21 (33%) ‘‘Don’t know,’’ and 7 did not record an answer.
DISCUSSION Hospitals need to develop effective surveillance programs appropriate to their local patient demographics and priorities.14 This profile highlights data that influence the planning of a statewide, hospital-acquired infection surveillance program for the Victorian smaller public acute care hospitals–all located in nonremote areas. Some results are applicable to all the smaller
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Table 3. Hospitals and surgical procedure group numbers Annual estimates for the 44 hospitals performing surgery
Surgical procedure group NNIS classified surgical procedure groups Abdominal hysterectomy Appendectomy Cesarean section Cholecystectomy Gastric Head and neck Herniorrhaphy Hip prosthesis Knee prosthesis Open fracture reduction Prostatectomy Skin grafts Non-NNIS classified surgical procedure groups Carpal tunnels Dilation and curettage Tonsillectomy Tubal ligation Urology Varicose veins Vasectomy Total
1. No. hospitals performing surgical group
2. Total no. of procedures performed
3. No. of hospitals performed #100 procedures
4. No. of hospitals performed $100 procedures
5. Total no. of procedures performed for column 4 hospitals
32 29 30 29 4 5 34 15 15 10 12 24
854 855 1397 2008 452 695 2737 120 168 540 177 300
31 28 26 24 2 4 25 14 14 9 11 23
1 1 4 5 2 1 9 1 1 1 1 1
128 240 615 1018 435 695 1751 120 168 540 177 300
40 36 30 34 15 33 39 466
1605 4326 1702 1232 2483 1063 1381 24,095
38 21 26 30 8 31 37 402
2 15 4 4 7 2 2 64
240 3509 607 491 2003 247 228 13,512
hospitals. Some important differences, however, between larger and smaller hospitals and between smaller hospitals of different acute care bed size are also demonstrated. In the smallest hospitals, there was a greater proportion of aged care beds. It would therefore be appropriate, as has occurred in preexisting surveillance programs (Table 2), for these hospitals to focus primarily on different infections. Published methods for long-term care facilities suggest monitoring commonly acquired respiratory tract, urinary tract, eye, ear, nose, mouth, skin, gastrointestinal, and systemic infections.15 The larger hospital ICU and HRN surveillance modules that target critically ill patients are not applicable to the smaller hospitals. In a recent US study, 57.9% of small rural hospital respondents had an ICU.4 In this profile, however, such critical care units were nearly nonexistent. It appears that, although invasive procedures may be initiated in the Victorian smaller hospitals, critically ill patients are usually transferred to accessible larger hospitals. Chronic hemodialysis patients are susceptible to infections and are an important population for inclusion in hospital-acquired infection surveillance programs.
The CDC currently has a national outcome-based surveillance program to monitor these infections.16 A similar program could be undertaken in Victoria; however, in the 109 CDC participating centers, the median number of patients treated each month was 56 (range, 7-284), compared with a median of 3 in the profiled smaller hospitals. The small sample size and correspondingly small number of incidents would probably limit meaningful analysis of any results. The majority of the smaller hospitals are ineligible to participate in the larger hospital SSI surveillance module (This result is consistent with Table 2, which highlights that the percentage of hospitals participating in preexisting SSI surveillance programs increased with an increasing number of acute care beds). For the smallest hospitals, this is primarily because they did not perform surgery. The other smaller hospitals performed limited numbers of procedures within the NNIS surgical groups and/or performed mostly procedures within the low infection risk surgical groups. Knowledgeable qualified personnel should manage the process of collecting surveillance data.14 This profile indicates an encouragingly high level of formal qualifications held by IC personnel–an improvement on previous related Australian studies17,18 and most
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likely a consequence of additional DHS funding made available in late 1999 to Victorian hospitals to improve IC outcomes. It, however, is unknown whether these qualifications include epidemiology as a key subject. Epidemiologic principles form the foundation of effective surveillance programs and therefore should be included in related education plans. No recommendations currently exist about the amount of time that IC persons should allocate to a surveillance program. This profile emphasizes, however, that the smaller hospital surveillance program has to be time efficient. Although almost all of the hospitals had at least 1 IC person employed, the designated variable IC hours were limited. In addition to this, as it has been highlighted elsewhere, many smaller hospital IC persons have other important responsibilities such as clinical care, occupational health and safety, and wound management.4,18 Across Victoria, the data show that 14% of total acute care bed days for smaller hospitals were ‘‘same day’’ admissions. This combined with the emphasis for decreasing the average length of ‘‘multiday’’ admissions highlights the need for postdischarge surveillance to be established if the magnitude of hospital-acquired infections is to be thoroughly documented. The best method to accomplish this, however, remains unclear.14 To achieve the aim of benchmarking data, the use of uniform case definitions would need to be implemented. In addition, a variety of sources would need to be consistently used to complete and confirm required surveillance datasets.14 From a previous DHS Victorian hospital survey, many acute care health services conducted laboratory-based surveillance combined with clinical ward rounds to identify infections.19 This profile suggests that the timely use of this case finding method may be impeded because of the absence of on-site pathology services and infrequent reporting in smaller hospitals. Computerization of surveillance systems can facilitate the functioning of the surveillance process. The acquisition, analysis, and exchange of information can be more proficiently provided.14 It is noted that the smaller hospitals in this profile would require further advancement in information management technology to obtain fully these potential benefits. The methodology used for this paper was subject to certain limitations. First, definitions and methodology to be used by the IC personnel for collecting the preplanning survey data were not detailed. Second, the small number of hospitals that did not participate in the preplanning survey had on average a lower number of acute care beds, total beds, and acute care to total bed ratio. A comparison of means for these variables with the corresponding means for the participating hospitals did not, however, provide strong evidence
that these characteristics influenced the tendency for hospitals to respond correctly to the survey. Despite these limitations, the data collected provide a useful and comprehensive profile to assist in the planning of a hospital-acquired infection surveillance program for Victorian, public, acute care, smaller hospitals. The program needs to be quite different to that developed for the larger hospitals and for smaller hospitals of significantly different acute care bed size. There are notable influential differences between these hospitals in local patient demographics and priorities. The authors thank the Clinical Governance Unit, Office of Chief Clinical Advisor, Department of Human Services and Melbourne Health; the IC personnel in the participating hospitals; VICNISS staff; and Graeme Steele and Stephen Gow at the Department of Human Services, who assisted with data collection.
References 1. Australian Bureau of Statistics 2003. Available from: www.abs.gov.au. Accessed April 27, 2005. 2. Department of Human Services. Infection control in Victorian public hospitals 1998 Available from: www.health.vic.gov.au. Accessed April 27, 2005. 3. Centers for Disease Control and Prevention. Monitoring hospital acquired infections to promote patient safety–United States 19901999. MMWR 2000;49:149-53. 4. Stevenson KB, Murphy CL, Samore MH, Hannah EL, Moore JW, Barbera J, et al. Assessing the status of infection control programs in small rural hospitals in the western United States. Am J Infect Control 2004; 32:255-61. 5. Scheckler WE. Hospital epidemiology and infection control in small hospitals. In: Mayhall CG, editor. Hospital epidemiology and infection control. Philadelphia: Lippincott Williams and Wilkins; 1999. p. 1455-9. 6. Scheckler WE, Peterson PJ. Nosocomial infection: prevalence, risk and control in small community and rural hospitals. Infect Control 1986;7: 144-8. 7. Scheckler WE, Peterson PJ. Nosocomial infections in 15 rural Wisconsin hospitals: results and conclusions from 6 months of comprehensive surveillance. Infect Control 1986;7:397-402. 8. Britt MR, Burke JP, Nordquist AG, Wilfert JN, Smith CB. Infection control in small hospitals: prevalence surveys in 18 institutions. JAMA 1976;236:1700-3. 9. Britt MR. Infectious diseases in small hospitals: prevalence of infections and adequacy of microbiology services. Ann Intern Med 1978;89: 757-60. 10. Australian Government Department of Health and Aging. Accessibility/ Remoteness Index of Australia (ARIA) Available from: www.health. gov.au. Accessed April 27, 2005. 11. The Aged Care Standards and Accreditation Agency Ltd. Available from: www.accreditation.aust.com. Accessed April 27, 2005. 12. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance System. NNIS System Report, Data summary from January 1992 to June 2002, Issued August. Atlanta, GA; 2002. 13. Australian Council of Healthcare Standards. Infection Control Indicators Version 2. NSW, 2003. Available from: www.achs.org.au. Accessed April 27, 2005. 14. Gaynes RP, Horan TC. Surveillance of nosocomial infections. In: Mayhall GC, editor. Hospital epidemiology and infection control. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 1285-316. 15. McGeer A, Campbell B, Emori TG, Hierhoizer WJ, Jackson MM, Nicolle LE, et al. Definitions of infection for surveillance in long term care facilities. Am J Infect Control 1991;19:1-7.
Bennett et al 16. Tokars JI, Miller ER, Stein G. New national surveillance system for hemodialysis-associated infections: initial results. Am J Infect Control 2002;30(5):288-95. 17. Cadwallader H, Nikoletti S. Current Australian nosocomial infection surveillance activities: a survey of Australian Infection Control Association (AICA) members. Australian Infect Control 2001;1:7-17.
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18. Murphy CL, McLaws ML. Who coordinates infection control programs in Australia? Am J Infect Cotrol 1999;27: 291-5. 19. Department of Human Services. Infection control in Victorian public health services 2002-2003. Available from: www.health.vic.gov.au. Accessed April 27, 2005.