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Hospital-wide surveillance: Perspective for the practitioner
EPORTS
nwide surveillance: ective for the practitioner
Charlottesville,
Va.
Although hospital-wide surveillance for nosocomial infections has been advocated by the Centers for Disease Control (CDC)* and more recently by the Joint Commission for Accreditation of Hospitals (JCAH),z often infection control practitioners have limited resources and personnel. As a result, they cannot develop a comprehensive surveillance system. Since some authorities think that the single most important aspect of an infection control program is surveillance,” hospitals with limited resources should define areas of priority for surveillance, which efficientiy identify hospital acquired infections. The data from our B-year experience utilizing total hospital surveillance have identified highrisk areas and procedures related to nosocomial infections. The results of our experience are summarized in this paper. ATERIALS
AND
METHODS
The University of Virginia Hospital, a 700bed teaching hospital serving the city of Charlottesville (population approximately 40,000), is a referral hospital for most of the western half of the state of Virginia and surrounding areas. Approximately 20,000 patients are admitted annually for a mean hospitalization time of 9 days. There are four main intensive care areas in the hospital accounting for 7% of hospital beds: a surgical intensive care unit (ICU) (16 beds), a neonatal ICU (16 beds), a medical ICU (8 beds),
From the Departments of Nursing, Pediatws, and Medicine, University of Vlrglnia Medical Center, Charlottesville. Reprint requests: Sandra L Landry, R.N., University of Virginia Medicai Center, Box 473, Charlottesville, VA 22908.
and burn unit (6 beds). Both the surgical ZCU and the burn unit are “open wards” without partitions to separate individual patients. In the newborn ICU up to six babies may be housed in the same room. Patients are either in private or semiprivate rooms in the medical ICU. A Kardex surveillance system has been in use since September 1972. Total hospital-wide surveillance is performed weekly by four trained mfection control practitioners who review the treatment Kardex (nursing care plan) on each nursing unit to identify patients at increased risk for developing a nosocomial infection. The charts of patients at increased ris for evidence of nosocomial infections.” nosocomial infection has been identified, the data are entered daily into our computer system. Since 1975, surveillance has been performed in critical care areas and on the obstetrics ward twice weekly. Laboratory monitoring for positive blood cultures is performed weekly to ensure 100% sensitivity of surveillance for nosocomial bloodstream infections. Since mid-1978, a computerized system for storage and retrieval of surveillance data has enabled us to analyze past and present infection data on a weekly basis. Computer storage of surveillance data has assisted in more effective and rapid identification and investigation of outbreaks and clusters. A line listing of all nosocomial infections by site and unit is generated and analyzed each week. The line listings provide a ready reference for the practitioner, ensuring that hospital-acquired infections of previous weeks are not counted again. At the end of the month, a monthly nosocomial infection surveillance report is distributed to the professional staff and administration of the 019&6553/82/020066+02$0020/G
0 1982 Assoc. Pract. lniect. Control
Volume IO Number 2
Hospital-wide mrveiilance
May, 1982
hospital. The report contains information on e monthly overall infection rates, service specific rates, a list of pathogens, unit-specific reports, site-specific reports, and an antibiogram report.
etween 1972 and 1980,160,OOOpatients were admitted to the University of Virginia Hospital. The mean overall rate of nosocomial infections was 8%, with a monthly range of 4% to 11% and a trend of slightly higher rates during the winter months. The critical care areas have a mean annual infection rate of 23%, compared to 6% for the general medicine and surgical wards. In the 2-year period 1979 to 1981,45% of all bloodstream infections occurred within the critical care areas, and 46% of these bacteremias were caused by gram-negative rods. In 1980, 40% (21153) of nosocomial Staphylococcus auzu.s bacteremias were methicillinresistant, with 57% (12/21) of these occurring in the critical care setting. In addition to the intravenous line, 73% of surgical ICU patients had at least one intravascular device. Of these patients, 3% to 17% developed a device-related bloodstream infection. In 1980, the overall rate of hospital-acquired pneumonias was 1% (223/21,508), of which 48% (1061223) occurred within the critical care areas. Fifty-two percent (15129) of the S. aurem pulmonary infections occurred in the critical care setting, with 27% (4115) being resistant to methicillin. Of all methicillin-resistant S. aureleMsisolates from patients with nosocomial pneumonia, 417 (57%) were in critical care areas. Since 1978, we have identified seven outbreaks by ongoing surveillance and analysis of incomputerized data. All seven outbreaks volved primarily or exclusively patients in the critical care areas? Investigation resulted in the detection of the reservoir in five of the outbreaks, and prevention of new cases was a result of infection control measures instituted.
In our experience with hospital-wide surveillance and data analysis, the documentation of the critical care units as high-risk areas for
nosocomial infections and increasing antibiotic resistance has directed our surveillance time and in-service activities to these units and to the high-risk procedures performed in these areas. These patients are seriously ill and at increased risk with or without invasive devices. By closely monitoring nosocomial infections in these areas, the infection control practitioner can assess the effect of changes in procedures and new products. Interpretation of our I980 data indicated that the most efficient surveillance for life-threatening infections occurred in the critical care units. SUMMARV Hospitals with limited resources need to velop priorities and might consider directing their surveillance efforts in the critical care areas. Once surveillance in these areas has been completed, the practitioner can focus attention on other areas of the hospital, including inservice activities. The preliminary report of the CDC’s study of the efficacy of nosocomial infection control (SENIC studyYj showed a direct correlation between the Ievel of in-service activities and subsequent infection rates. In conclusion, goals for a cost effective surveillance system program should reflect (1) priority areas for surveillance, (2) decision as to what information needs reporting, and (3) effective utilization of data to direct preventive efforts and outbreak investigation. References 1. Garner JS, Bennett JV, Scheckler WE, Maki DG, Brachman PS: Surveillance of nosocomial infection. In Proceedings of the International Conference on Mosocomial Infections. Baltimore, 1971, Waverly Press, pp. 277-281 2. Joint Commission on the Accreditation of Hospitals: Infection control. In Accreditation Manual for Hospitals. Chicago, 1980, The Commission, pp. 71-78 PS: Basic consideration of hospital infec3. Brachman tions. Ivz Hospital Infections, Bennett JV, Bra&man P, editors. Boston, 1979, Little, Brown & Co., pp. 3-7 4. Wenzel RP, Osterman CA, Hunting KJ, Gwaltney JM Jr: Hospital-acquired infections. I. Infection surveillance in a university hospital. Am J Epidemiol 103:251, 1976 5. Wenzel RP, Osterman CA, Donowitz LG, et al: Identification of procedure-related nosocomial infections in high risk patients. Rev Infect Dis 3:701-707, 1981 6. Haley RW: The SENIC study. Presented at the Second International Symposium on Mosocomiai Infections, Atlanta, August 1980
nwide surveillance: ective for the practitioner
Charlottesville,
Va.
Although hospital-wide surveillance for nosocomial infections has been advocated by the Centers for Disease Control (CDC)* and more recently by the Joint Commission for Accreditation of Hospitals (JCAH),z often infection control practitioners have limited resources and personnel. As a result, they cannot develop a comprehensive surveillance system. Since some authorities think that the single most important aspect of an infection control program is surveillance,” hospitals with limited resources should define areas of priority for surveillance, which efficientiy identify hospital acquired infections. The data from our B-year experience utilizing total hospital surveillance have identified highrisk areas and procedures related to nosocomial infections. The results of our experience are summarized in this paper. ATERIALS
AND
METHODS
The University of Virginia Hospital, a 700bed teaching hospital serving the city of Charlottesville (population approximately 40,000), is a referral hospital for most of the western half of the state of Virginia and surrounding areas. Approximately 20,000 patients are admitted annually for a mean hospitalization time of 9 days. There are four main intensive care areas in the hospital accounting for 7% of hospital beds: a surgical intensive care unit (ICU) (16 beds), a neonatal ICU (16 beds), a medical ICU (8 beds),
From the Departments of Nursing, Pediatws, and Medicine, University of Vlrglnia Medical Center, Charlottesville. Reprint requests: Sandra L Landry, R.N., University of Virginia Medicai Center, Box 473, Charlottesville, VA 22908.
and burn unit (6 beds). Both the surgical ZCU and the burn unit are “open wards” without partitions to separate individual patients. In the newborn ICU up to six babies may be housed in the same room. Patients are either in private or semiprivate rooms in the medical ICU. A Kardex surveillance system has been in use since September 1972. Total hospital-wide surveillance is performed weekly by four trained mfection control practitioners who review the treatment Kardex (nursing care plan) on each nursing unit to identify patients at increased risk for developing a nosocomial infection. The charts of patients at increased ris for evidence of nosocomial infections.” nosocomial infection has been identified, the data are entered daily into our computer system. Since 1975, surveillance has been performed in critical care areas and on the obstetrics ward twice weekly. Laboratory monitoring for positive blood cultures is performed weekly to ensure 100% sensitivity of surveillance for nosocomial bloodstream infections. Since mid-1978, a computerized system for storage and retrieval of surveillance data has enabled us to analyze past and present infection data on a weekly basis. Computer storage of surveillance data has assisted in more effective and rapid identification and investigation of outbreaks and clusters. A line listing of all nosocomial infections by site and unit is generated and analyzed each week. The line listings provide a ready reference for the practitioner, ensuring that hospital-acquired infections of previous weeks are not counted again. At the end of the month, a monthly nosocomial infection surveillance report is distributed to the professional staff and administration of the 019&6553/82/020066+02$0020/G
0 1982 Assoc. Pract. lniect. Control
Volume IO Number 2
Hospital-wide mrveiilance
May, 1982
hospital. The report contains information on e monthly overall infection rates, service specific rates, a list of pathogens, unit-specific reports, site-specific reports, and an antibiogram report.
etween 1972 and 1980,160,OOOpatients were admitted to the University of Virginia Hospital. The mean overall rate of nosocomial infections was 8%, with a monthly range of 4% to 11% and a trend of slightly higher rates during the winter months. The critical care areas have a mean annual infection rate of 23%, compared to 6% for the general medicine and surgical wards. In the 2-year period 1979 to 1981,45% of all bloodstream infections occurred within the critical care areas, and 46% of these bacteremias were caused by gram-negative rods. In 1980, 40% (21153) of nosocomial Staphylococcus auzu.s bacteremias were methicillinresistant, with 57% (12/21) of these occurring in the critical care setting. In addition to the intravenous line, 73% of surgical ICU patients had at least one intravascular device. Of these patients, 3% to 17% developed a device-related bloodstream infection. In 1980, the overall rate of hospital-acquired pneumonias was 1% (223/21,508), of which 48% (1061223) occurred within the critical care areas. Fifty-two percent (15129) of the S. aurem pulmonary infections occurred in the critical care setting, with 27% (4115) being resistant to methicillin. Of all methicillin-resistant S. aureleMsisolates from patients with nosocomial pneumonia, 417 (57%) were in critical care areas. Since 1978, we have identified seven outbreaks by ongoing surveillance and analysis of incomputerized data. All seven outbreaks volved primarily or exclusively patients in the critical care areas? Investigation resulted in the detection of the reservoir in five of the outbreaks, and prevention of new cases was a result of infection control measures instituted.
In our experience with hospital-wide surveillance and data analysis, the documentation of the critical care units as high-risk areas for
nosocomial infections and increasing antibiotic resistance has directed our surveillance time and in-service activities to these units and to the high-risk procedures performed in these areas. These patients are seriously ill and at increased risk with or without invasive devices. By closely monitoring nosocomial infections in these areas, the infection control practitioner can assess the effect of changes in procedures and new products. Interpretation of our I980 data indicated that the most efficient surveillance for life-threatening infections occurred in the critical care units. SUMMARV Hospitals with limited resources need to velop priorities and might consider directing their surveillance efforts in the critical care areas. Once surveillance in these areas has been completed, the practitioner can focus attention on other areas of the hospital, including inservice activities. The preliminary report of the CDC’s study of the efficacy of nosocomial infection control (SENIC studyYj showed a direct correlation between the Ievel of in-service activities and subsequent infection rates. In conclusion, goals for a cost effective surveillance system program should reflect (1) priority areas for surveillance, (2) decision as to what information needs reporting, and (3) effective utilization of data to direct preventive efforts and outbreak investigation. References 1. Garner JS, Bennett JV, Scheckler WE, Maki DG, Brachman PS: Surveillance of nosocomial infection. In Proceedings of the International Conference on Mosocomial Infections. Baltimore, 1971, Waverly Press, pp. 277-281 2. Joint Commission on the Accreditation of Hospitals: Infection control. In Accreditation Manual for Hospitals. Chicago, 1980, The Commission, pp. 71-78 PS: Basic consideration of hospital infec3. Brachman tions. Ivz Hospital Infections, Bennett JV, Bra&man P, editors. Boston, 1979, Little, Brown & Co., pp. 3-7 4. Wenzel RP, Osterman CA, Hunting KJ, Gwaltney JM Jr: Hospital-acquired infections. I. Infection surveillance in a university hospital. Am J Epidemiol 103:251, 1976 5. Wenzel RP, Osterman CA, Donowitz LG, et al: Identification of procedure-related nosocomial infections in high risk patients. Rev Infect Dis 3:701-707, 1981 6. Haley RW: The SENIC study. Presented at the Second International Symposium on Mosocomiai Infections, Atlanta, August 1980