046 VICNISS AnnReport · Post-discharge surveillance 13 Results 15 Confidence intervals 16 Data 17 ... surgical site infection rates by risk category ... 2004 hip arthroplasty surgical

VICNISSHospital Acquired Infection ProjectYear 3 report–June 2005

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VICNISS Hospital Acquired Infection Project Year 3 report June 2005

Published by the Victorian Government Department of Human Services, Melbourne, Victoria

© Copyright State of Victoria 2005

This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

Also published on www.health.vic.gov.au/infcon and www.vicniss.org.au

Authorised by the Victorian Government, 555 Collins Street, Melbourne.

Printed by Thaker Print, PO Box 517, Blackburn Victoria 3130

July 2005

(050614)

Clinical review of area mental health services 1997-2004 iii

Contents

Foreword 1

Acknowledgments 2

Abbreviations 2

Executive summary 3

Introduction—why is hospital acquired infection surveillance important? 5

What is VICNISS? 6

VICNISS surveillance activities in our hospitals 7

Type 1 surveillance 8

Adjusting for risk 11

Type 2 surveillance 12

Post-discharge surveillance 13

Results 15

Confidence intervals 16

Data 17

How is Victoria tracking? 33

How the hospitals use these data 35

Limitations and challenges 36

What’s next for VICNISS? 37

Conclusions 38

Spreading the word about VICNISS 39

Glossary 42

Appendix A: VICNISS Advisory Committee terms of reference 46 (revised August 2004)

Appendix B: VICNISS Coordinating Centre staff 52

References 54

iv Victorian Outcome Measurement Training Manual–2nd edition 2003

List of figures

Figure 1: Cumulative intensive care unit central line-associated 17 bloodstream infection rate (95 per cent CI) - Group A1 hospitals

Figure 2: Cumulative intensive care unit central line-associated 18 bloodstream infection rate (95 per cent CI) - ‘Other’ hospitals

Figure 3: Frequency of causative organisms in intensive care unit 19 central line-associated bloodstream infections

Figure 4: Neonatal intensive care unit peripheral line-associated 20 bloodstream infection rate. April 2004 - December 2004

Figure 5: Neonatal intensive care unit central line-associated 21 bloodstream infection rate. April 2004 - December 2004

Figure 6: Comparison of 2003 and 2004 coronary artery bypass graft 22 surgical site infection rates by risk category

Figure 7: Frequency of causative organisms in surgical site infections 23 following coronary artery bypass grafts

Figure 8: Comparison of 2003 and 2004 hip arthroplasty surgical site 24 infection rates by risk category

Figure 9: Frequency of causative organisms in surgical site infections 25 following hip prosthesis

Figure 10: Comparison of 2003 and 2004 knee arthroplasty surgical site 26 infection rates by risk category

Figure 11: Frequency of causative organisms in surgical site infections 27 following knee prosthesis

Figure 12: Surgical antibiotic prophylaxis in Type 1 hospitals - 28 antibiotic choice in relation to guidelines

Figure 13: Surgical antibiotic prophylaxis in Type 1 hospitals - 29 timing of administration of first dose in relation to guidelines

Figure 14: Surgical antibiotic prophylaxis in Type 2 hospitals 31

Figure 15: Type 2 hospital compliance with measles/mumps/rubella guidelines 32

List of tables

Table 1: Rates for laboratory-confirmed bloodstream infections, 30 methicillin-resistant Staphylococcus aureus infections and outpatient haemodialysis events

VICNISS Hospital Acquired Infection Project: Year 3 report 1

This is the second annual report of the VICNISS Hospital Acquired Infection Surveillance Coordinating Centre, which was established in February 2002. The primary objective of VICNISS is to reduce the number of hospital-acquired infections. To achieve this, we must first accurately measure the current rates of hospital-acquired infection. The infection rates summarised in this report represent the most comprehensive and detailed hospital-acquired infection surveillance project undertaken in Victoria.

The data presented in this report are aggregated data from all participating hospitals, and hospitals use these data to compare their own infection rates with state infection rates and to measure their performance. This report provides 2004 data from larger hospitals participating in the surveillance program, which is based on the United States’ National Nosocomial Infection Surveillance program (Type 1 surveillance), and compares them with data from 2003 reported in the Year two report from March 2004. Data from the smaller hospitals participating in a new surveillance program (Type 2 surveillance), which focuses on infection prevention process and staff health, are also presented.

This report highlights the progress made in the VICNISS project in the past 12 months. Important developments during this period were the implementation of surveillance activities in smaller Victorian public hospitals, reporting on the use of surgical antibiotic prophylaxis in large and small Victorian public hospitals, and details of the reported bacteria causing infections after surgery and in intensive care units.

Overall, 117 Victorian public hospitals now perform uniform surveillance for hospital-acquired infections, and the role of VICNISS has become an accepted part of hospital efforts in quality patient care.

Dr Mike Richards Director, VICNISS Coordinating Centre

Foreword

The Clinical Governance Unit, Office of the Chief Clinical Advisor, Metropolitan Health and Aged Care Services Division, Department of Human Services produced this report on the VICNISS Coordinating Centre’s activities in collaboration with the centre.

A special acknowledgment is extended to all the infection control nurses and staff who participated in this project. Their ongoing support and commitment has made this project achievable and this second report possible.

AbbreviationsACHS Australian Council for Healthcare Standards

ASA American Society of Anesthesiology

CABGS Coronary artery bypass grafts

CDC Centers for Disease Control and Prevention (United States)

CLABSI Central line-associated bloodstream infection

ICC Infection Control Consultant

ICU Intensive care unit

KISS Krankehaus Infektions Surveillance System (Germany)

LC-BSI Laboratory confirmed bloodstream infection

MRO Multi-resistant organism

MRSA Methicillin-resistant Staphylococcus aureus

NNIS National Nosocomial Infection Surveillance (United States)

NNL Neonatal unit

OBD Occupied bed days

RC Risk Category

SSI Surgical site infection

VAP Ventilator associated pneumonia

VICNISS Victorian Hospital Acquired Infection Surveillance System

Acknowledgments

2 VICNISS Hospital Acquired Infection Project: Year 3 report


This report describes progress in the Victorian Hospital Acquired Infection Surveillance (VICNISS) project between February 2004 and February 2005, including developments in surveillance activities in large hospitals, and the pilot and roll-out of the surveillance program in smaller, usually rural, Victorian public hospitals. Data from the past 12 months from large and small hospitals are presented.

The surveillance program for large hospitals has been somewhat modified from the United States’ National Nosocomial Infection Surveillance (NNIS) program on which it was based, according to the local needs and infection control resources. Feedback from key stakeholders was captured through direct contact with hospitals, hospital visits, the VICNISS Advisory Committee, the VICNISS Technical Advisory Group, user groups, and contacts developed to address specific questions. The neonatal intensive care unit surveillance program (NNL) is an example of where substantial changes were made after local consultation. However, most activities remain consistent with NNIS methods and definitions, allowing international comparisons.

Coronary artery bypass graft surgery, major joint prosthetic surgery, and caesarean sections remain the favoured surgical procedures for post-operative surveillance. Hospitals receive reports on their data quarterly. For some risk categories, surgical site infection rates appear higher than those reported by the United States’ NNIS and German Krankehaus Infektions Surveillance System hospitals; however, differences in post-operative practices, including hospital stay and readmission of patients with surgical site infections, might account for some of these differences. A consistent method of post-discharge surveillance has not yet been developed and, because all infections are not identified, there remain some uncertainties over whether rates are directly comparable. Risk factor data required to categorise patients for their risk of post-operative infection has substantially improved in quality.

No trend in the aggregate surgical site infection rates over time has yet been identified in the short history of the VICNISS program.

Surgical antibiotic prophylaxis data are reported here for the first time, and identify important areas for process improvement. This module is undergoing further development and will be a particular focus in monitoring hospitals’ response to surveillance information.

Surveillance of intensive care unit acquired infection has also identified high rates of central line-associated bloodstream infections and ventilator-associated pneumonia in some hospitals and these hospitals are addressing this.

Another first in this report is that data from neonatal units are included.

Hospitals are now able to examine their own infection rates and, if they are higher than expected, to seek local factors that might explain such differences from aggregate data. Hospitals with higher than expected infection rates are formally notified through their infection control team and, more recently, also through their executive sponsor. They are able to evaluate the impact of interventions on infection rates. These approaches have not previously been possible.

Executive summary

Smaller hospitals are now part of statewide initiatives in hospital infection prevention. A quite different program of surveillance to that used in larger hospitals was developed after extensive consultation and feedback. The initial response has been that measures of process have been more useful to the hospital than outcome measures. Relatively few major surgical site infections, primary bloodstream infections, and haemodialysis infections have been identified in these hospitals. Methicillin-resistant Staphylococcus aureus infection, although relatively infrequent in these hospitals, is often imported with the patients at the time of their transfer to these hospitals. Surgical antibiotic prophylaxis has been identified as an important process that can be further improved.

The coordinating centre’s resources for much of this time have been focused on generating individual hospital reports, pending development of software that will allow each hospital to write their own reports. This has also been a time of considerable academic activity, with presentations of information generated from the centre locally, nationally and, recently, internationally. Important areas of research underway include a costing study of infections of major joint prostheses, an examination of the application of NNIS risk adjustment for surgical site infections in the Australian setting, and the quality of surgical antibiotic prophylaxis as delivered in Victorian public hospitals.

The most immediate challenges for the VICNISS program now are developing and implementing software at participating sites, and formally evaluating the surveillance program within the hospitals to assess the quality of data, practicalities of collection, and usefulness of the project in improving the quality of health care in our public hospitals.



Research has demonstrated that up to one third of hospital-acquired infections can be prevented with high intensity hospital acquired infection surveillance and control programs (Haley et al. 1985). Assuming Australian infection rates are similar to those in the United States, as many as 150,000 hospital-acquired infections might occur annually (Australian Infection Control Association Expert Working Group 2001).

Surveillance of hospital acquired infection assists in identifying:

• Whether there is an infection problem

• The magnitude of the problem

• The factors that contribute to infections

Surveillance also allows hospitals and clinicians to measure the effectiveness of strategies that are implemented to decrease infection rates.

Infection rate data should be used in a positive way to improve the quality and safety of health care. Going through the process of undertaking surveillance will not usually influence infection rates appreciably itself, unless surveillance is linked to a prevention strategy. The information must be fed back to those who need to know-infection control nurses, surgeons, intensive care clinicians and hospital management-for it to be used to drive change.

Introduction—why is hospital-acquired infection surveillance important?

The VICNISS Hospital Acquired Infection Surveillance System for larger hospitals is based on the United States’ Centers for Disease Control and Prevention’s National Nosocomial Infection Surveillance (NNIS) system, which was established in 1970. NNIS surveillance activities, designed for hospitals with more than 100 beds, are targeted at those patients at highest risk of hospital-acquired infections-namely, patients after surgery and patients in adult and neonatal intensive care units.

The NNIS system has been widely used and is generally considered to be the most developed and validated hospital infection surveillance system worldwide. A cornerstone of the system is the use of clinically validated risk adjustment methods, and there is a high level of acceptance by clinicians in the United States and other developed countries. Most importantly, the NNIS system has been proven to reduce hospital-acquired infections.

The VICNISS Coordinating Centre collects and analyses data from individual hospitals, and reports quarterly to participants and the Department of Human Services on aggregate, risk-adjusted, procedure-specific infection rates. This information contributes to the development of accurate and reliable benchmarks against which hospitals and health services can assess their performance.

A multidisciplinary team comprising infection control nurses, epidemiologists, infectious diseases physicians, an information technology officer and an education officer staffs the centre.

What is VICNISS?



As a result of work previously undertaken by the VICNISS Coordinating Centre, VICNISS surveillance is now well established in 98 per cent of all public acute hospitals in Victoria. The challenge for the future of VICNISS surveillance will be to continue to evolve the system to meet the needs of all key stakeholders. Outlined below are the two types of surveillance activities that VICNISS currently offers, together with details of the future directions of the Type 1 and Type 2 programs.

VICNISS surveillance activities in our hospitals

Type 1 surveillance is derived from the traditional NNIS surveillance activities. Three surveillance components have been introduced in the VICNISS program. These components are based on modules introduced into the NNIS system in 1986. Each surveillance component is a self-contained protocol, which focuses on a particular high-risk patient group. Substantial information on infected and uninfected patients is collected in these components, allowing the hospitals and the VICNISS Coordinating Centre to calculate infection rates.

The surveillance modules are:

A - Surgical Site (SSI) Surveillance Component

Hospitals are encouraged to undertake surveillance on two or more VICNISS surgical procedure groups. It is recommended that hospitals select surgical procedure groups within which they perform at least 100 procedures a year at their institution.

B - Intensive Care Unit Surveillance (ICU) Component

Hospitals with intensive care units are encouraged to undertake surveillance on:

• Central line-associated bloodstream infections

• Ventilator-associated pneumonia.

C - Neonatal Intensive Care Unit (NNL) Component

Hospitals with neonatal intensive care units are encouraged to undertake surveillance on:

• Central line-associated bloodstream infections

• Peripheral line-associated bloodstream infections

Each hospital is able to choose which surveillance activity it undertakes, taking into consideration the priorities within the strategic plan of the infection control program at each hospital, the number of procedures, and infection control resources. It is recommended that all surveillance activities be conducted prospectively.

Development of the VICNISS programType 1 surveillance was implemented in three phases. The coordinating centre initially recruited ten hospitals to commence Phase I in November 2002. Phase I was used to identify any issues and to modify the system prior to rollout to other hospitals. Following the implementation of Phase I, surveillance was then rolled out in Phases II and III over nine months to the remaining large hospitals.

Type 1 surveillance



Surgical-site infections

All hospitals with more than 100 beds contribute data on the surgical-site infections (SSI) component. Data from 15 procedure groups on more than 20,000-targeted surgical procedures has been submitted. Data from the SSI component have been well accepted, as has the use of the NNIS Risk Index to stratify infection rates and allow for appropriate comparisons. Hospitals undertaking procedures associated with highest morbidity and mortality, such as coronary artery bypass grafts and hip and knee joint arthroplasty, contribute large amounts of data to VICNISS. Differences in hospital rates when compared to the aggregate have resulted in many hospitals reviewing their own practices for managing surgical patients for specific procedures.

Infections acquired in intensive care units

For intensive care unit (ICU) surveillance, the VICNISS program initially simplified the NNIS intensive care unit surveillance methods, which traditionally have reported ICU-acquired infections at all infection sites. VICNISS hospitals were requested only to report rates of central line-associated bloodstream infections and ventilator-associated pneumonia rates per 1,000 days of device use. At these two infection sites, the United States’ NNIS system reports infection rates, and these sites are those most important in terms of associated morbidity, cost and generating antibiotic use.

Following up patients 48 hours after being discharged from an ICU for ventilator-associated pneumonia, which was demanding on infection control consultants’ time, was abandoned when no additional episodes of pneumonia were identified in this period in any participating ICUs.

The surveillance definitions for central line-associated bloodstream infections were further simplified from the NNIS definitions following feedback from infection control consultants. NNIS definitions for primary bloodstream infections include two entities, ‘laboratory confirmed’ and ‘clinical sepsis’, where the blood cultures are either negative or not taken. Identifying this latter group requires more clinical judgement, and reporting is more subjective. NNIS investigators have previously reported that less than 10 per cent of central line-associated bloodstream infections notified to them are considered to be in the ‘clinical sepsis’ category. After discussion with participants, only laboratory-confirmed bloodstream infections are now reported to VICNISS.

Surgical antibiotic prophylaxis

A major initiative during 2004 was the reporting of data on surgical antibiotic prophylaxis submitted to VICNISS over a 20-month period. Surgical antibiotic prophylaxis has been shown to be effective in reducing the incidence of surgical wound infections for many types of surgery. Measuring compliance of surgical antibiotic prophylaxis against recommended guidelines is a commonly used audit tool.

This report presents statewide data assessing compliance with current recommendations for antibiotic prophylaxis in Victorian public hospitals with more than 100 beds. Reporting to individual hospitals on compliance with published recommendations for surgical antibiotic prophylaxis has recently commenced. It is hoped that regular reporting on antibiotic prophylaxis as part of the statewide surveillance program and the ability of

hospitals to be able to compare their performance with statewide data will result in improvements in documentation and, most importantly, compliance with guidelines which promote the optimal use of antibiotics.

Infections acquired in neonatal intensive care units

Neonatal intensive care unit surveillance methods were also modified after discussions with a committee of senior local neonatalogists. The neonatalogists expressed concerns over the diagnosis of ventilator-associated pneumonia in this patient group because other pulmonary conditions might be clinically difficult to separate from pneumonia. The neonatalogists requested that surveillance of antibiotic usage, instead of surveillance of ventilator-associated pneumonia, in these patients be considered. This will be considered in future program developments. Data on peripheral line-associated bloodstream infections are collected because the neonatalogists expressed concern that many neonates have peripheral lines in-situ and requested the monitoring of related bloodstream infections.



Surgical patientsWhen comparing infection rates in hospitals, it is important to be sure that the comparisons are fair. Some patients are at greater risk of infection because they have other medical conditions or their surgery was complex and prolonged: the infection rate is likely to be higher in these patient groups. Comparing the infection rate for these very sick patients to the rate for patients who are fitter or have had simpler operations would not be reasonable or useful. One patient, previously well, having an elective cholecystectomy (removal of the gall bladder) through keyhole surgery is at lower risk of post-operative infection than is another patient with complex medical problems who is also having the gall bladder removed, but through a large incision in the abdomen in a prolonged procedure that is technically complex due to local problems with previous surgery. Extending this notion, the mix of patients treated can influence individual hospital infection rates: a hospital with a greater proportion of sick patients would be expected to have higher infection rates.

VICNISS applies a risk stratification process, which groups patients according to their likelihood of developing an infection. This is known as risk adjustment. Many factors are thought to increase the likelihood of infection, and investigators continue to search for new risk factors and explanations of why certain factors increase risk. In most cases, hospital-acquired infections are the result of many factors.

Surgical-site infection reporting is grouped according to the type of operation and the NNIS Risk Index, which the United States’ Centers for Disease Control and Prevention researchers developed in 1991. The NNIS Risk Index has received international acceptance as the most useful risk index for stratifying surgical-site infection rates. Using this risk index, patients are categorised into one of four risk groups (ranging from zero to three) depending on three criteria: the length of surgery, the degree of bacterial contamination of the wound, and the patient’s American Society of Anesthesiology (ASA) score. The higher the risk index score, the higher is the risk of infection. The infection rate in risk index group three is therefore higher than the infection rate in risk index group two. Similarly, the infection rate in risk index group two is higher than that in risk index group one, and so on. No method of risk-adjustment is perfect, and the VICNISS Coordinating Centre is undertaking work to test how well the NNIS Risk Index performs in the Australian setting.

Stratifying intensive care unit dataVICNISS reporting of ICU infection rates recognises that the greatest risk factor for acquisition of infections in ICUs is the use of ‘invasive devices’, such as mechanical ventilation and central venous catheters. Rates are expressed as infections per days of mechanical ventilation or per central venous catheter day.

Not all ICUs are alike in their mix of patients. It would be expected that the major teaching hospital ICUs with sicker patients would have higher infection rates than other units whose patient populations have less complex conditions. Therefore, following recommendations of the VICNISS Advisory Committee, data from ICUs are categorised into two groups: ‘Group A1’ and ‘Other’. Even though the hospitals in Group A1 have more in common with each other than the ICUs in the ‘Other’ group, we acknowledge that differences might still exist in the patient populations of the ICUs in Group A1. There might also be some unanticipated differences between these two groups of ICUs. In smaller hospital ICUs, who do not care for patients after cardiac surgery, the rates of ventilator-associated pneumonia may be influenced by a greater proportion of sicker medical patients requiring ventilation for longer periods, and an absence of surgical patients requiring short duration ventilation.

Adjusting for risk

Type 2 surveillance methods are the methods used for smaller (fewer than 100 acute beds) Victorian public hospitals.

Most hospital acquired infection surveillance in large hospitals performing high volumes of surgery and with intensive care units is directed at producing risk-adjusted infection rates. These can be compared with aggregate rates compiled from statewide data. This type of surveillance is not appropriate for many smaller hospitals because the numbers of infections and patients at risk of infection are too small to calculate valid and reliable infection rates.

Appropriate surveillance programs for smaller hospitals are not well documented in the international literature. In many ways Australia is in a unique situation with its numbers of smaller rural hospitals serving the population.

The approach VICNISS is using is that surveillance of surgical patients and calculation of infection rates is only recommended for hospitals with sufficient surgical throughput. Alternative methods are more appropriate for most smaller hospitals.

Process indicator surveillance

An alternative to infection (or outcome) surveillance is ‘process’ surveillance, which aims to monitor processes that have been demonstrated to affect outcomes, rather than the outcomes (infections) themselves. The most effective surveillance activities monitor processes that have been shown to be most closely associated with the outcome. For example, correct administration of prophylactic antibiotics to surgical patients has been shown to be effective in reducing the rate of surgical site infections. Therefore, for hospitals performing low volumes of surgery, it might be more appropriate to monitor the administration of prophylactic antibiotics-a frequent event-than to calculate an infection rate, which is based on much lower numbers of events or infections.

Other processes that have been demonstrated to be closely related to infection outcomes include handwashing, catheter insertion techniques, staff vaccination programs for influenza, and Measles vaccination of health care workers.

Surgical site infection rates

This surveillance, used in Type 1 hospitals, is suitable for some Type 2 hospitals. Data are collected on all patients undergoing certain types of surgery and these patients are monitored for infection following surgery. Risk adjustment is identical to that used in Type 1. Caution must be exercised when interpreting rates based on small numbers of patients because a single infection can cause a potentially misleading increase in the infection rate.

Reporting of selected infections and related events

Other approaches used include reporting of events, such as multi-resistant organisms, serious wound infections, and bloodstream infections. In some cases, these can be used to calculate a rate of infections using occupied bed days or another similar broad measure of throughput as a denominator. This can be useful in identifying clusters of these events at a single hospital or at a particular group of hospitals.

Type 2 surveillance



Type 2 surveillance modules

Module Aim

Surgical antibiotic prophylaxis

To improve the selection, timing and duration of prophylactic antibiotics used to prevent infections at the surgical site

Health care workers and measles vaccination

To assess Victorian public hospitals’ policy compliance with the National Health, Medical and Research Council and the Department of Human Services recommendations for susceptible health care workers, specifically in regard to measles-mumps-rubella (MMR) vaccination. To determine current status of health care workers susceptible to measles

Health care workers and Hepatitis B vaccination

To assess Victorian public hospitals’ policy compliance with the National Health, Medical and Research Council recommendations. To identify uptake of Hepatitis B vaccine offered to at-risk health care workers

Peripheral venous catheter use

To optimise the safety associated with the use of peripheral venous catheters. Short term peripheral venous catheters are inserted in peripheral veins for vascular access. Although the incidence of local or bloodstream infections associated with peripheral venous catheters is usually low, serious infectious complications can result in considerable annual morbidity.

Multi-resistant organism

To provide a method for individual hospitals to measure infections caused by methicillin-resistant Staphylococcus aureus or vancomycin resistant enterococci

Primary laboratory- confirmed bloodstream infection

To provide a method for individual hospitals to measure primary laboratory-confirmed bloodstream infections

Outpatient haemodialysis centre

To provide a method for individual outpatient haemodialysis centres to monitor bloodstream and vascular access infections and intravenous Vancomycin use

Occupational exposure

To provide a method for individual hospitals to measure reported occupational exposures

Surgical site infection

To provide a method for hospitals to monitor targeted surgical procedures

Surgical infection report

To ensure certain significant but infrequent deep and organ space infections are counted. The following infections are to be recorded: deep surgical site infections and organ space surgical site infections.

Type 2 surveillance activities were rolled out to 89 hospitals in the first half of 2004, following a pilot program in 14 hospitals. By July 2004, every Victorian public hospital was contributing data to the VICNISS program.

The participating sites have warmly received the Type 2 program. Feedback has indicated the process indicator surveillance modules have been most useful in helping hospitals to identify deficits in existing infection control processes.

There has been considerable interest at the national and international levels in the success of the Type 2 program. Recently, a presentation on the development of the VICNISS Type 2 program was made at an international infection control conference in Los Angeles.

Infections included in the calculation of VICNISS rates include only those diagnosed during hospital admission or a subsequent readmission for the infection. As with NNIS, VICNISS does not currently include post-discharge surveillance because no simple reliable method of identifying infections after discharge has been developed. VICNISS recognises that because not all hospital-acquired infections are likely to be identified without rigorous post-discharge surveillance, the rates reported here are an underestimate of the true rate of infection. Some studies have reported up to a 50 per cent increase in infection rates when post-discharge surveillance is conducted. However, the more serious infections that occur after discharge lead to patient readmission, and the VICNISS methods will capture these.

Post-discharge surveillance



Data for the following are presented:

Type 1: a) intensive care unit - central line-associated bloodstream infections

b) neonatal intensive care unit:

i) central line-associated bloodstream infections

ii) peripheral line-associated bloodstream infections

c) surgical site infection rates for:

i) coronary artery bypass grafts

ii) hip arthroplasty

iii) knee arthroplasty

iv) caesarean section

d) compliance with surgical antibiotic prophylaxis guidelines.

Type 2:a) multi-resistant organism infection rate

b) outpatient haemodialysis event rate

c) laboratory-confirmed bloodstream infections

d) compliance with measles vaccination guidelines

e) compliance with surgical antibiotic prophylaxis guidelines.

Results

Whenever VICNISS generates an infection rate, it is always accompanied by 95 per cent confidence intervals. The calculated rates reported here are generally estimates of the ‘true’ rate. The true rate could be calculated only from accurate data on every relevant surgical procedure in Victoria. Infection rates are therefore provided with 95 per cent confidence intervals, which provide a measure of the estimated rate’s closeness to the true rate. The 95 per cent confidence intervals for the VICNISS rates are provided in the tables and also displayed in the figures by a vertical line crossing through the top of the bar.

Example of a confidence intervalConfidence intervals provide a good idea of the true infection rate and are important to consider when interpreting these rates. They represent the lowest and highest values the true rate is likely to be. An infection rate based on 10,000 surgical procedures that resulted in 1,000 infections would be calculated to be 10 per cent, with upper and lower confidence intervals of 9.4 and 10.6 respectively. This means the true rate is highly likely to lie between 9.4 per cent and 10.6 per cent. The same infection rate of 10 per cent would also be calculated from a sample of ten procedures with one infection, but the confidence interval would be 0.3-44.5 (meaning the true rate lies between 0.3 per cent and 44.5 per cent), which suggests the calculated rate of 10 per cent might be very different from the true rate. Generally, the larger the sample size, the better the estimate of the rate, and thus the narrower the confidence intervals.

Confidence intervals



Chart 1: Cumulative intensive care unit central line-associated bloodstream infection rate (95 per cent CI), Group A1 hospitals

Chart 1 demonstrates the cumulative rate of central line-associated bloodstream infections in the intensive care units of the Group A1 hospitals at every quarter since the beginning of the VICNISS program. As the program progresses, the rate appears to be settling around six infections for every 1,000 central line days. This chart represents data submitted from six hospitals.

Data

Chart 2: Cumulative intensive care unit central line-associated bloodstream infection rate (95 per cent CI), ‘Other’ hospitals

Chart 2 demonstrates the cumulative rate of central line-associated bloodstream infections in the intensive care units of the ‘Other’ hospitals at every quarter since the beginning of the VICNISS program. As the program progresses, the rate appears to be settling around 1.5 infections for every 1,000 central line days. This chart represents data submitted from seven hospitals.



Chart 3: Frequency of causative organisms in intensive care unit central line associated bloodstream infections

Chart 3 demonstrates the frequency of causative organisms identified in central line-associated bloodstream infections from all intensive care units. This chart represents data submitted from 14 hospitals.

Chart 4: Neonatal intensive care unit peripheral line-associated bloodstream infection rate. April 2004 - December 2004

Chart 4 demonstrates the peripheral line-associated bloodstream infections in neonatal intensive care units. Rates are stratified by birthweight because babies with lower birthweight are generally considered to be at a higher risk of developing infection. This explains the trend seen in this chart. The wide confidence intervals indicate the numbers in each of the categories are small, which is expected since this surveillance only commenced during 2004. This chart represents data submitted from three hospitals.



Chart 5: Neonatal intensive care unit central line associated bloodstream infection rate. April 2004 - December 2004

Chart 5 demonstrates the peripheral line-associated bloodstream infections in neonatal intensive care units. Rates are stratified by birthweight because babies with lower birthweight are generally considered to be at a higher risk of developing infection. This explains the trend seen in this chart.

The wide confidence intervals indicate the numbers in each of the categories are small, which is expected since this surveillance only commenced during 2004. This chart represents data submitted from three hospitals.

Chart 6: Comparison of 2003 vs 2004 coronary artery bypass graft surgical-site infection rate by Risk Category

Chart 6 demonstrates the coronary artery bypass graft surgical-site infection rates for 2003 and 2004 compared with the equivalent rate reported by NNIS. The 2004 rate for risk category one is slightly higher than that reported for 2003, and significantly higher than the NNIS rate (3.4). In risk category two, the rate in 2004 is lower than reported in 2003 and similar to the rate reported by NNIS (5.4). This chart represents data submitted from six hospitals.



Chart 7: Frequency of causative organisms in surgical-site infections following coronary artery bypass grafts

Chart 7 demonstrates the frequency of causative organisms in surgical site infections following coronary artery bypass grafts. The most common organism is Staphylococcus aureus, at 46 per cent. Of these, we know that 15.8 per cent were methicillin-resistant Staphylococcus aureus, but this figure could be higher because not all hospitals provide information on resistance patterns.

Chart 8: Comparison of 2003 and 2004 hip arthroplasty surgical-site infection rates by risk category

Chart 8 demonstrates the hip arthroplasty surgical-site infection rates for 2003 and 2004 compared with the same risk category reported by NNIS. Unlike 2003, the rate reported for 2004 in risk category zero is similar to that reported by NNIS. In risk category one, the 2004 rate continues to be significantly higher than the NNIS rate of 1.7.



Chart 9: Frequency of causative organisms in surgical-site infections following hip prosthesis

Chart 9 demonstrates the frequency of causative organisms in surgical-site infections following hip arthroplasty. The most common organism is Staphylococcus aureus, at 70 per cent. Of these, we know 38.2 per cent were methicillin-resistant Staphylococcus aureus, but this figure could be higher because not all hospitals provide information on resistance patterns.

Chart 10: Comparison of 2003 and 2004 knee arthroplasty surgical-site infection rates by risk category

Chart 10 demonstrates the knee arthroplasty surgical-site infection rates for 2003 and 2004 compared with the same risk category reported by NNIS. In contrast to 2003, the 2004 rate in risk category zero is significantly higher than the NNIS rate. The rates for risk categories one and two are similar to the NNIS rates.



Chart 11: Frequency of causative organisms in surgical site infections following knee arthroplasty

Chart 11 demonstrates the frequency of causative organisms in surgical site infections following knee arthroplasty. The most common organism is Staphylococcus aureus, at 70 per cent. Of these, we know 25 per cent were methicillin-resistant Staphylococcus aureus, but this figure could be higher because not all hospitals provide information on resistance patterns.

Chart 12: Surgical antibiotic prophylaxis in Type 1 hospitals - antibiotic choice in relation to guidelines

Chart 12 demonstrates compliance of choice of prophylaxis with guidelines. Concordant procedures represent a choice of drug either completely concordant with national guidelines or considered adequate for the procedure. Inadequate procedures indicate a drug choice considered not to provide adequate protection from the likely range of pathogens. The high percentage of inadequate procedures for appendectomy might be partly due to prophylaxis being withheld as patients have previously been administered antibiotics in the emergency department.



Chart 13: Surgical antibiotic prohylaxis in Type 1 hospitals - timing of administration of first dose in relation to guidelines

Chart 13 demonstrates compliance of timing of antibiotic administration (first dose) with guidelines. Concordant procedures represent timing as recommended in the guidelines, non-concordant procedures are those in which timing was not in accordance with guidelines. The number of procedures for this analysis was reduced because documentation is less reliable for this than for choice of antibiotic.

Table 1: Rates for laboratory-confirmed bloodstream infections, methicillin-resistant Staphylococcus aureus infections and outpatient haemodialysis events

Objective

Number of participating

hospitalsNumber

of eventsOccupied bed days

Infection rate 95% CI

LCBSI 48 hours post admission per 10,000 occupied bed days

85 19 266,049 0.7 0.4-1.1

MRSA infection within 48 hours of admission per 10,000 occupied bed days

82 36 221,817 1.6 1.1-2.2

MRSA infection 48 hours post admission per 10,000 occupied bed days

82 16 221,817 0.7 0.4-1.2

Outpatient haemodialysis events per 100 dialysis patient months

14 2 - 0.47 0.1-1.7

These rates are for the period 1 May to 31 December 2004. The laboratory-confirmed bloodstream infections and methicillin-resistant Staphylococcus aureus rates are calculated by dividing the number of infections by the number of occupied bed days and multiplying by 10,000. Therefore, the rate is expressed as number of infections per 10,000 occupied bed days. The outpatient haemodialysis event rate is calculated by dividing the number of events by the number of patient months and dividing by 100. The rate is then expressed as number of events per 100 patient months.

Type 2 surveillance program



Chart 14: Surgical antibiotic prophylaxis in Type 2 hospitals

Chart 14 demonstrates compliance of choice, timing and duration of prophylaxis with guidelines.

Choice: Concordant procedures represent a choice of drug either completely concordant with national guidelines or considered adequate for the procedure. Inadequate procedures indicate a drug choice considered not to provide adequate protection from the likely range of pathogens. Nineteen hospitals contributed to this data set. Of 773 procedures, the choice was considered adequate in 52 per cent of the procedures. ‘Unknown’ denotes that an antibiotic was administered, but the name was not provided.

Timing: Demonstrates compliance of timing of antibiotic administration (first dose) with guidelines. Concordant procedures represent timing as recommended in the guidelines, non-concordant procedures are those in which timing was not in accordance with guidelines. Nineteen hospitals participated in the surgical antibiotic prophylaxis module. Of 632 procedures, the timing was considered concordant in 50 per cent of the procedures. ‘Unknown’ indicates that the time of administration was not recorded.

Duration: For the purposes of VICNISS reporting, duration was categorised into either ‘procedures where duration of all prophylactic antibiotics was less than 24 hours’, ‘procedures where duration of all prophylactic antibiotics was greater than 24 hours’ or ‘unknown’. Nineteen hospitals participated in the surgical antibiotic prophylaxis module. Of 632 procedures, the duration was considered adequate in 80 per cent of the procedures. ‘Unknown’ indicates the duration was not recorded.

Chart 15: Type 2 hospital compliance with measles/mumps/ rubella guidelines

Chart 15 indicates that most hospitals have a documented policy, but not all are consistent with the National Health and Medical Research Council guidelines. Just over 5 per cent of employees are considered susceptible.



Victoria now has an established standardised surveillance program for hospital-acquired infections in all of its public hospitals. This is a major step forward from the situation identified in a survey of public hospitals in the late 1990s, which was that surveillance resources, including staffing and information technology, were limited, there was little standardisation of methods, and data frequently were not fed back to treating clinicians to drive improvements in quality of care.

The program still needs formal evaluation and refinement, and expansion to important new areas, including staff health and infections in haemodialysis patients, but already represents clearly the most ambitious state program in Australia.

Large (Type 1) hospitals

Intensive care unit and neonatal intensive care unit data

Intensive care unit data are collected from ICUs in six Department of Human Services-classified ‘A1’ hospital ICUs and seven ‘Other’ ICUs. Data on central line-associated bloodstream infections have shown considerable variation between hospitals. It is acknowledged that separating ICUs into these two groups does not take into account all differences in patient mix within the state. In ‘A1’ hospitals, the central line-associated bloodstream infection rate is steady at approximately six per 1,000 central line days.

Three hospitals contributed to the neonatal data. As with the United States’ data, we found the central line-associated bloodstream infection rate to be higher in babies belonging to lower birthweight categories.

Surgical site infection data

All larger hospitals regularly contribute data on infections after surgical procedures. Although the infection rates are broadly comparable to the United States’ NNIS rates, in some risk categories and for some procedures, state aggregate rates are higher than United States’ NNIS rates. There are limitations in these comparisons (see later), but international data are useful for benchmarking, particularly until we have a large enough volume of local data for all procedures under surveillance.

There is no clear trend in infection rates as compared with the previous year-a not unexpected finding. Overseas experience is that overall improvements in surgical site infection rates should be expected only after several years, but individual hospitals address their problem areas as the data come to hand.

Surgical antibiotic prophylaxis data

Surgical antibiotic prophylaxis has been shown to be effective in reducing the incidence of surgical wound infections for many types of surgery. Measuring compliance of surgical antibiotic prophylaxis against recommended guidelines is a commonly used audit tool worldwide.

This is the first time data on antibiotic prophylaxis have been routinely collected and reported for all public hospitals in Victoria. The results obtained are comparable with those published widely overseas, and show there is room for improvement in the administration and documentation of prophylactic antibiotics. Most published data are from short-term audits.

How is Victoria tracking?

In contrast to this approach, VICNISS has a commitment to regular reports on compliance. These have been well received and have generated a great deal of discussion. As a result of this feedback, it is expected that improvements will be seen in a relatively short time frame.

Small (Type 2) hospitalsInfections caused by methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, primary bloodstream infections and outpatient haemodialysis events were, as expected, infrequent events in these smaller hospitals. Although this program does not generate meaningful infection rates, reporting of deep surgical wound infections, infections with multi-resistant organisms, and complicating haemodialysis, should identify any unexpected clusters of serious hospital-acquired infection if they were to occur in the future. Further analysis of these data by hospital size and rural region is to be undertaken to potentially improve its usefulness.

The process indicator dataset, which offered a larger sample size, was considered to be a more productive application of infection control resources by the participating hospitals. Both surgical antibiotic prophylaxis and measles vaccination of employees were demonstrated to be sub-optimal. These modules are now targeted areas for improvement and reassessment.

Overall, the novel 2004 Type 2 surveillance program was achievable, in that almost all of the eligible hospitals were able to submit data.

For 2005, as requested by the participating hospitals, the program has been expanded to include modules examining health care workers’ Hepatitis B and influenza vaccination uptake, infection prevention practices relating to peripheral venous catheter use, and hospital staff occupational exposures to bloodborne pathogens.



All data are posted quarterly on the password-protected VICNISS website. Infection control consultants at participating hospitals are notified when the data are updated. Hospitals can download data in a number of different formats, which allows them to present the information in a variety of ways.

At most hospitals VICNISS data are presented at a number of different forums, including infection control committees, quality committees, surgical and intensive care units, and hospital wards. In 2004, some hospitals also started using VICNISS data in their annual quality of care reports to demonstrate their own performance against the state aggregate. Differences in hospital rates when compared with the aggregate have resulted in many hospitals reviewing their own practices for managing surgical patients for specific procedures.

How the hospitals use these data

As with all surveillance programs, it is important to recognise the limitations of the program. As reported in last year’s annual report, the initial plan was to implement the NNIS definitions and method exactly as they had been implemented in the United States. However, after consultation with the infection control teams of participating hospitals, small modifications to the NNIS system were required to meet the needs of the participating hospitals.

Ideally, data collection would use standardised software linked to relevant patient information systems to maximise efficiency. In the majority of hospitals at present, data collection using paper forms continues. In conjunction with the Department of Human Services and other key stakeholders, major work has been done on developing specifications for a software surveillance program which all hospitals undertaking Type 1 surveillance could use. It is anticipated that this software development will commence in the near future.

The infections identified in VICNISS are only those diagnosed during hospital admission or a subsequent readmission for the infection. We recognise infections occur post-discharge, and these are not counted in the data. Therefore, the true hospital acquired infection rates will be higher than those reported.

No surveillance program is perfect. Surveillance definitions might not be as specific as definitions for research, because the data collection must be practical, ongoing and not consume too many resources. The VICNISS program does not undertake surveillance for every surgical procedure because this coverage would not be an efficient use of infection control resources. It is more efficient to focus on areas of highest risk. Some important surveillance activities are yet to be addressed, such as surveillance for bloodstream infections in dialysis patients (an important challenge) and for the use of certain expensive and broad-spectrum antibiotics. The VICNISS Coordinating Centre continues to work with infection control staff to develop programs for hospital-acquired infections in cancer patients and to improve information on the use of prophylactic antibiotics before surgery. To perfectly risk-adjust infection rates is impractical because it would require enormous data collection resources to identify and collect all risk factors for infection after each surgical procedure. We will work towards improving risk-adjustment, and, to improve our program, we are collaborating with people already collecting risk data on these surgical procedures for other reasons. Efforts to improve risk-adjustment will become easier as hospital patient information system technologies improve.

Limitations and challenges



VICNISS will be refined over time to meet the needs of the hospitals, consumer groups and the government. This work will include:

• Continuing to improve the surveillance program, refining existing modules and examining new areas of importance, through understanding local needs and resources as communicated by direct hospital contact, the VICNISS Advisory Committee, the VICNISS Technical Advisory Group, and user groups of hospital infection control consultants

• Developing new software to assist with data collection, analysis and reporting in large participating hospitals. Through the software, the Coordinating Centre will seek ways of linking to existing hospital information systems to make data collection more efficient and to improve data quality

• Continuing to develop relevant consumer information, including identifying a user-friendly method of providing information about infection rates that can be used for public reporting

• Promoting educational initiatives in infection prevention surveillance, including expanding the interactive web-based program for infection control nurses that was launched in 2004

• Examining improvements in surveillance for special patient groups (for example, patients with cancer) in collaboration with participating hospitals

• Continuing to undertake research initiatives, and presenting the results of the study of the costs of orthopaedic surgical site infections

• Collaborating with surgical groups, such as the Australian Cardiothoracic Society and the Australian Orthopaedic Association, in identifying specific risk factors for surgical-site infections in these patient groups

• Ensuring hospitals, surgeons and nursing staff have confidence in the infection rate data, risk-adjustment, definitions and benchmarks

• Ensuring VICNISS is sustainable and robust over the long term, and responds to new hospital-acquired surveillance needs as they are identified

• Examining international and local developments in surveillance of hospital acquired infections, in an effort to identify useful improvements to the program for Victoria

• Contributing the VICNISS experience to national programs in this area.

What is next for VICNISS?

The VICNISS Hospital-Acquired Infection Surveillance System has now been implemented in 28 larger and 89 smaller Victorian public hospitals. It provides hospitals with a tool to measure continuous quality improvement that increases patient safety.

The information presented in this report provides a baseline for undertaking future monitoring at a hospital and state level; however, it remains limited by cumbersome data collection processes, which will be improved once a uniform software program is implemented. Both Type 1 and 2 surveillance systems will be further refined and consolidated over the next few years to ensure the system is reliable, efficient and able to provide information clinicians and consumers can use.

Although VICNISS has achieved a great deal since its establishment, with a major emphasis on education to ensure consistent use of definitions and understanding of methods, it is important to take care with comparisons. It is a priority that we move on to validation studies to ensure data quality is high, information is reliable, and infection rates are accurate. It is expected that public reporting of data will occur once the system has been validated and a meaningful method of providing this information to consumers is identified.

Conclusions



VICNISS is a first for Australia. Therefore, it is important that information about its implementation and outcomes to date is shared nationally and internationally. VICNISS Coordinating Centre staff have presented at a number of conferences and submitted articles to peer review journals. Recently, staff made oral and poster presentations at the Society for Healthcare Epidemiology of America Annual Scientific Meeting in Los Angeles and at the Communicable Diseases Control Conference in Sydney.

Below is a comprehensive list of papers and presentation originating from VICNISS.

Publications 1. Bennett, NJ, Bull, AL, Dunt, DR, Gurrin, LC, Richards MJ, Russo PL & Spelman, DW,

‘A profile of smaller hospitals - planning for a novel Statewide surveillance program, Victoria, Australia’. (Accepted by Am J Infect Control, March 2005.)

2. Russo, PL, Bull, AL, Bennett, NJ, Boardman, CJ, Burrell, SJ, Motley, JE, Friedman, ND & Richards, MJ, ‘Infections after coronary artery bypass graft surgery in Victorian hospitals - VICNISS Hospital Acquired Infection Surveillance’. (Australia & New Zealand Journal of Public Health, Vol.29(3) p244_8.)

3. Russo, PL, Bull, AL, Bennett, NJ, Boardman, CJ, Burrell, SJ, Motley, JE, Friedman, ND & Richards, MJ, ‘The establishment of a statewide surveillance program for hospital-acquired infections in large Victorian public hospitals’. (Accepted by Am J Infect Control, June 2005.)

Prepared for submission4. Bull, AL, Russo, PL, Bennett, NJ, Boardman, CJ, Burrell, SJ, Motley, JE, Friedman,

ND & Richards, MJ, ‘Compliance with surgical antibiotic prophylaxis - reporting from a Statewide surveillance program’. (Submitted to J Hosp Infect, April 2005.)

5. Friedman, ND, Bull, AL, Russo, PL, Boardman, CJ, Bennett, NJ, Burrell, SJ, Motley, JE, Gurrin, L & Richards, MJ, ‘Performance of the NNIS Risk Index in predicting surgical site infections in an Australian setting’. (Submitted to Infect Control Hosp Epidemiol, April 2005.)

Abstracts and presentations 1. Bennett, NJ, Berry, KS, Boardman, CJ, Bull, AL, Burrell, SJ, Friedman, ND, Motley, JE,

Richards, MJ & Russo, PL 2004, ‘The potential for surgical site infection rate surveillance in smaller Victorian public acute care hospitals’, Paper presented at the Australian Infection Control Association Third Biennial Conference, Hobart, June 2004.

2. Bennett, N, Berry, K, Boardman, C, Bull, A, Burrell, S, Friedman, N, Motley, J, Richards, M & Russo, P 2004, ‘Piloting a statewide smaller hospital nosocomial infection surveillance program’, Paper presented at the New South Wales Infection Control Conference, Sydney, 15 September 2004.

3. Bennett, N, Berry, K, Boardman, C, Bull, A, Burrell, S, Friedman, N, Motley, J, Richards, M & Russo, P 2005, ‘The potential for surgical site infection rate surveillance in smaller acute public hospitals, Victoria, Australia’, Paper presented at the Society for Healthcare Epidemiology of America 15th Annual Scientific Meeting, Los Angeles, 9-12 April 2005.

Spreading the word about VICNISS

4. Bennett, N, Berry, K, Boardman, C, Bull, A, Burrell, S, Friedman, N, Motley, J, Richards, M & Russo, P 2005, ‘A statewide smaller hospital nosocomial infection surveillance program: the first report, Victoria, Australia’, Paper presented at the Society for Healthcare Epidemiology of America 15th Annual Scientific Meeting, Los Angeles, 9-12 April 2005.

5. Bennett, N, Berry, K, Boardman, C, Bull, A, Burrell, S, Friedman, N, Motley, J, Richards, M & Russo, P 2005, ‘A statewide smaller hospital nosocomial infection surveillance program: the first report, Victoria, Australia’, Paper presented at the Communicable Diseases Control Conference, Sydney, May 2005.

6. Bull, A, Russo, PL, Bennett, NJ, Boardman, C, Burrell, SJ, Motley, JE, Friedman, ND & Richards, M 2005, ‘Surgical antibiotic prophylaxis in Victorian public hospitals: early results from VICNISS, a statewide surveillance program’, Paper presented at the Society for Healthcare Epidemiology of America 15th Annual Scientific Meeting, Los Angeles, 9-12 April 2005.

7. Friedman, ND, Bull, AL, Russo, PL, Boardman, CJ, Bennett, NJ, Burrell, SJ, Motley, JE, Gurrin, L & Richards, MJ 2005, ‘Performance of the NNIS Risk Index in predicting surgical site infections in an Australian setting’, Paper presented at the Society for Healthcare Epidemiology of America 15th Annual Scientific Meeting, Los Angeles, 9-12 April 2005.

8. Friedman, ND, Bull, AL, Russo, PL, Boardman, CJ, Bennett, NJ, Burrell, SJ, Motley, JE, Gurrin, L & Richards, MJ 2005, ‘Performance of the NNIS Risk Index in predicting surgical site infections in an Australian setting’, Paper presented at the Association for Practitioners in Infection Control and Epidemiology 32nd Educational Conference and International Meeting, Baltimore, Maryland, 19-23 June 2005.

9. Motley, JE, Bull, AL, Boardman, CJ, Bennett, NJ, Berry, KS, Burrell, SJ, Friedman, ND, Russo, PL & Richards, MJ 2004, ‘Development of the VICNISS web based interactive learning package for infection control consultants’, Paper presented at the Australian Infection Control Association Third Biennial Conference, Hobart, June 2004.

10. Richards, MJ, Bull, AL, Bennett, NJ, Boardman, CJ, Burrell, SJ, Motley, JE, Friedman, ND, Berry, KS, Russo, PL 2004, ‘Establishment of a statewide surveillance program for hospital acquired infections in large adult acute care Victorian public hospitals’, Paper presented at the Australian Infection Control Association Conference, Hobart, June 2004.

11. Richards, MJ, Russo, PL, Bull, AL, Bennett, NJ, Boardman, CJ, Burrell, SJ, Motley, JE & Friedman, ND 2004, ‘Early data from the VICNISS surveillance program for hospital-acquired infection in Victoria’, Paper presented at the Australasian Society for Infectious Diseases Annual Scientific Meeting, Alice Springs, May 2004.

12. Richards, MJ, Russo, PL, Bull, AL, Bennett, NJ, Boardman, CJ, Burrell, SJ, Motley, JE & Friedman, ND 2004, ‘Establishment of a statewide surveillance program for hospital acquired infections in large adult acute care Victorian public hospitals’, Paper presented at the 2nd Australasian Conference on Safety and Quality in Health Care, Canberra, 9-10 August 2004.

13. Richards, MJ, Russo, PL, Bull, AL, Bennett, NJ, Boardman, CJ, Burrell, SJ, Motley, JE & Friedman, ND 2004, ‘A statewide surveillance program for hospital-acquired infections in large Victorian public hospitals - early days and early data health outcomes 2004’, Paper presented at Perspectives in Population Health, 10th National Conference, Canberra, 15-16 September 2004.



14. Russo, PL, Bull, A, Bennett, NJ, Boardman, C, Burrell, SJ, Motley, JE, Friedman, ND & Richards, M 2004, ‘Nosocomial infection surveillance and epidemiology’, Paper presented at the 29th Australian and New Zealand Annual Scientific Meeting on Intensive Care, Melbourne, October 2004.

15. Russo, PL, Bull, A, Bennett, NJ, Boardman, C, Burrell, SJ, Motley, JE, Friedman, ND & Richards, M. 2005, ‘The establishment of a statewide surveillance program for hospital-acquired infections in large acute public hospitals, Victoria, Australia’, Paper presented at the Society for Healthcare Epidemiology of America 15th Annual Scientific Meeting, Los Angeles, 9-12 April 2005.

16. Russo, P, Bull, A, Bennett, NJ, Boardman, C, Burrell, SJ, Motley, JE, Friedman, ND & Richards, M 2005, ‘The establishment of a statewide surveillance program for hospital-acquired infections in large acute public hospitals, Victoria, Australia’, Paper presented at the Association for Practitioners in Infection Control and Epidemiology 32nd Educational Conference and International Meeting, Baltimore, Maryland, 19-23 June 2005.

17. Russo, PL, Bull, AL, Bennett, NJ, Boardman, C, Burrell, SJ, Motley, JE, Friedman, ND & Richards, MJ 2004, ‘The establishment of a statewide surveillance program for hospital-acquired infections in large Victorian public hospitals’, Paper presented at the Communicable Diseases Control Conference, Sydney, May 2005.

18. Russo, PL, Bull, AL, Bennett, NJ, Boardman, C, Burrell, SJ, Motley, JE, Friedman, ND & Richards, MJ 2005, ‘Data from larger hospitals participating in the VICNISS Hospital Acquired Infection Surveillance System - Victoria, Australia’, Paper presented at the Communicable Diseases Control Conference, Sydney, May 2005.

19. Russo, PL 2003, ‘An update from the VICNISS Coordinating Centre’, Paper presented at the Victorian Infection Control Professionals Association Conference, Melbourne, 22-23 May 2003.

Term Definition

ACHS Australian Council for Healthcare Standards

Aggregate data Data in the VICNISS Coordinating Centre’s database that are forwarded from hospitals

Antibiotic prophylaxis The use of antibiotics to prevent infections at the surgical site

ASA score American Society of Anesthesiology (ASA) score. This index is designed to pre-operatively assess the patient’s overall physical status. The score ranges from one for a healthy patient to five for a patient who is not expected to survive 24 hours post surgery (table 1)

Birthweight The first weight of the newborn

Bloodstream infection Presence of live pathogens in the blood, causing an infection. See also pathogen

Case A patient identified as having an infection

CDC Centers for Disease Control and Prevention (United States)

Central line A catheter (tube) that is passed through a vein to end up in the thoracic (chest) portion of the vena cava (the large vein returning blood to the heart) or in the right atrium of the heart. A central venous line is also called a central venous catheter. Sometimes, the ‘venous’ is omitted and it is called a central line or central catheter.

Central line-associated bloodstream infection

A bloodstream infection thought to have been caused by the presence of a central line

Cholecystectomy A surgical procedure to remove the gall bladder. This procedure can be performed through keyhole surgery. See laparoscopy

Coronary artery bypass graft surgery

A surgical procedure that creates new pathways around blocked or narrowed arteries to allow blood to reach the heart muscle again

Device days The number of days for which an intravenous catheter or ventilator is present in a patient

Epidemiology The study of populations to determine the frequency and distribution of disease and measure risks

Extrinsic risk A risk that is not inherent in the patient. Some forms of treatment are considered extrinsic risk factors, such as using invasive devices (such as catheters) or surgical procedures

Group A1 hospitals Large tertiary teaching hospital

Hospital-acquired infection or nosocomial infection

Any infection that occurs during or after hospitalisation that was not present or incubating at the time of the patient’s admission

Infection Invasion by and multiplication of pathogenic microorganisms in a bodily part or tissue, which might produce tissue injury and progress to disease

Intensive care unit A hospital unit that usually treats very sick patients. Patients in intensive care units are at a higher risk of developing infections because they are sicker than other patients

Intravascular device The device used to administer a solution into a vein

Intravascular device-related

Bloodstream infection linked to the presence of an intravascular device

Glossary



Laparoscopy Type of surgery in which a small incision (cut) is made in the abdominal wall through which an instrument (a laparoscope) is placed to permit structures within the abdomen and pelvis to be seen. A diversity of tubes can be pushed through the same incision in the skin. Probes or other instruments can thus be introduced through the same opening. In this way, a number of surgical procedures can be performed without the need for a large surgical incision. Often called keyhole surgery, the risk of infection in surgical procedures using a laparoscope is much less than for operations where a large incision is performed.

Methicillin resistant Staphylococcus aureus

A methicillin (antibiotic) resistant strain of Staphylococcus aureus

NNIS National Nosocomial Infection Surveillance. The NNIS system at the Centers for Disease Control and Prevention (Atlanta, Georgia) has served as an aggregating institution for United States’ hospitals for more than 30 years.

Nosocomial A term, which comes from two Greek words: ‘nosus’ meaning ‘disease’ and ‘komeion’ meaning ‘to take care of’. Hence, ‘nosocomial’ should apply to any disease contracted by a patient while under medical care. However, the definition of ‘nosocomial’ has been whittled down over the years and now refers to only hospitals; it is now synonymous with ‘hospital-acquired’.

Occupied bed days Number of days a patient is admitted to a hospital bed

Other hospitals All hospitals not defined as Group A1. See Group A1

Outcome indicator An indicator that measures an outcome (for example, infection rate)

Pathogen An agent of disease-that is, a disease producer. The term pathogen is used most commonly to refer to infectious organisms. These include microorganisms, such as bacteria, viruses and fungi

Peripheral line An intravenous catheter inserted into a vein, usually in the arm

Peripheral line-associated bloodstream infection

A bloodstream infection thought to have been caused by the presence of a peripheral line

Pneumonia Inflammation of one or both lungs. Pneumonia is frequently, but not always, due to infection. The infection can be bacterial, viral, fungal or parasitic

Point prevalence The number of events or people with a given disease or other attribute during a specified point in time

Prevalence The number of events (for example, instances of a given disease or other condition) in a given population at a designated time

Procedure-specific Related to a specific procedure. Procedure-specific infection rates for total hip replacements, for example, are only those infection rates that relate to total hip replacements

Process indicator An indicator that measures a process (for example, compliance with handwashing guidelines)

Prophylactic antibiotic An antibiotic given to a patient prior to a procedure to reduce the risk of infection

Prospective surveillance

Monitoring patients for infection while they are still in hospital. This surveillance can also include post-discharge surveillance, whereby patients are monitored for a set period once they leave hospital. See also retrospective surveillance

Rate A measure of the frequency of occurrence of an event phenomenon

Retrospective surveillance

Using chart review after the patient has been discharged from hospital as the sole means of identifying infections

Risk-adjustment A standardised method used to ensure intrinsic and extrinsic risk factors for a hospital acquired infection are considered in the calculation of hospital acquired infection rates

Risk index A means of stratifying patients according to their risk of infection. This then allows appropriate comparison of infection rates. See also risk adjustment

Standardisation A set of techniques used to remove, as far as possible, the effects of differences in age or other confounding variables when comparing two or more populations

Surgical-site infection An infection at the site of an operation (usually an incision) that is caused by the operation

Surveillance The ongoing systematic collection, analysis and interpretation of health data

Targeted surveillance Surveillance for infection in a specific area (for example, an intensive care unit) or for a specific procedure (for example, total hip replacement). Targeted surveillance for areas of concern is more efficient than doing surveillance across a whole hospital for all infections

Total hip replacement Surgery in which the diseased ball and socket of the hip joint are completely removed and replaced with an artificial joint

Total knee replacement

A surgical procedure in which damaged parts of the knee joint are replaced with an artificial joint

Transmission of infection

Any mechanism by which an infection is spread

Trend The general direction in which something tends to move. Surveillance involves observing the trend of infection rates to help identify any increases

Type 1 surveillance Surveillance activities designed for hospitals with more than 100 beds

Type 2 surveillance Surveillance activities designed for hospitals with fewer than 100 beds

Validation A program series of checks and challenges repeated periodically to establish the soundness and accuracy of the data

Ventilator A machine that mechanically assists patients to breathe (sometimes referred to as artificial respiration)

Ventilator-associated pneumonia

Pneumonia that is caused by the presence of the ventilator

VICNISS Advisory Committee

The committee that provides stakeholder advice to the VICNISS Coordinating Centre on the implementation, development and deliverables of the VICNISS program

VICNISS Coordinating Centre

The centre that collects and analyses data from individual hospitals and reports to participants and the Department of Human Services on aggregate, risk-adjusted, procedure-specific infection rates

VICNISS Technical Advisory Group

The group that provides the VICNISS Advisory Committee with recommendations about specific surveillance issues

VICNISS user groups User groups that provide a forum for program participants to support or liaise with the VICNISS Coordinating Centre and other participants



IntroductionThe Victorian Hospital Acquired Infection Surveillance System (VICNISS) and the Coordinating Centre were launched in August 2002. Through cooperation between the VICNISS Coordinating Centre and participating hospitals, a state-based hospital acquired infection database will be established over the next three years. VICNISS and the database will be used to:

• Promote a standardised approach to hospital acquired infection surveillance methods

• Provide aggregated risk-adjusted data on hospital-acquired infections, which enable health services and hospitals to undertake inter-hospital and international comparisons

• Promote the use of evidence-based information, validated methodology and analytical methods to permit timely recognition of hospital acquired infection and to promote prevention and early intervention

• Improve the way surveillance results are used in feedback, prevention and cost containment for individual hospitals and across metropolitan health services or statewide

• Promote the integration of surveillance of hospital-acquired infection with routine data collection and continuous quality improvement systems, and strategic management planning for infection control

• Promote consumer participation in the development of hospital-acquired infection performance measure reporting.

PurposeThe VICNISS Advisory Committee will provide stakeholder input and advice to the Coordinating Centre on the implementation and extension of VICNISS. The committee will advise the Coordinating Centre on the implementation, development and deliverables of VICNISS.

Terms of referenceThe VICNISS Advisory Committee will be a high level committee that will provide focus on strategies and deliverables for VICNISS, including:

• Ongoing review of aims, objectives and effectiveness of the role of VICNISS and its Coordinating Centre, in reducing hospital acquired infections

• Ensuring the development of VICNISS is in context with what already exists, particularly in relation to overlapping areas and gaps

• Providing advice on VICNISS broad business planning and service development, and progress on deliverables, including development of indicators for service quality and accessibility

• Providing comment on VICNISS hospital acquired infection surveillance reports

• Ensuring the potential benefit of the VICNISS project and Coordinating Centre is maximised, including measures to achieve maximum participation by health services

Appendix A: VICNISS Advisory Committee terms of reference (revised August 2004)

• Providing advice on the measures taken to ensure VICNISS and the Coordinating Centre have an effective communication strategy in place, including communication with the community and consumers

• Establish the mechanism for a technical reference group for the Coordinating Centre as required, on issues such as methods, definitions and the development, evaluation and implementation of VICNISS surveillance software.

Committee membershipMembership will be sought from key stakeholders, including the groups and individuals listed here, so that the Department of Human Services, hospital management, and professional and community groups are represented:

• Director, VICNISS Coordinating Centre

• Deputy Director, VICNISS Coordinating Centre

• Royal Australasian College of Surgeons

• Health services administrators (chief executive officer, director of nursing, or director of medicine)

• Department of Human Services representatives: Acute Health Division, and Public Health Division

• Consumer representative

• Victorian Infection Control Surveillance Project

• Epidemiology

• Victorian Infection Control Professionals Association

• Australasian Society for Infectious Diseases

• Victorian Advisory Committee on Infection Control Surveillance and Resistance Sub-committee

• Melbourne Health Service Management

• Rural infection control consultant

• Victorian Infectious Diseases Service

• Victorian Regional Committee - Joint Faculty of Intensive Care Medicine.

The VICNISS Advisory Committee can form working groups, co-opt members to the committee or working groups, and commission other activities as necessary.

The Department of Human Services appoints the Committee Chair and members. Members are appointed for a three-year term, with the option to extend (see also Appendix 3: Rules - attendance). Membership at August 2004 is at Appendix 1. The reporting/advisory relationships schema is at Appendix 2.



Meeting procedures• Meetings will occur in alternate months. In addition, there might be a requirement

to call an extraordinary meeting. There will be a minimum of five meetings a year.

• Quorum will be deemed to be half full membership + one. In the event the quorum is not achieved, the meeting will continue, but decisions will be ratified at the next meeting.

• Minutes-the activities of the committee-will be recorded, confirmed by the Chair, forwarded to members and retained on a formal registered file.

• The operating rules are at Appendix 3.

Reporting arrangementsThe committee will provide an annual report to the Department of Human Services, Melbourne Health and the Victorian Quality Council.

The Director, Office of the Chief Clinical Advisor is the principal Department of Human Services contact.

The Chief Executive Officer of Melbourne Health is the principal managerial contact for the VICNISS Coordinating Centre.

The Chair, the Director, Office of the Chief Clinical Advisor, Department of Human Services, the Chief Executive Officer, Melbourne Health, and the Director, VICNISS Coordinating Centre, will form a joint executive sponsorship committee.

Review of terms of referenceThe terms of reference of the committee will be ratified at the first meeting and will be reviewed as required by the Chair in consultation with the Department of Human Services.

Prefix First name Surname Representing

Mr Felix Pintado (Chair) Rural Chief Executive Officer

Mr Steve Anderson Executive Director, Corporate and Clinical Services

Mr Stephen Blamey Surgeon

Prof Graham Brown Victorian Infectious Diseases Service

Ms Kerrie Breckon Victorian Infection Control Professionals Association

Prof Lindsay Grayson Australasian Society for Infectious Diseases

Ms Sheila Hargrave Consumer

Ms Glenys Harrington Victorian Infection Control Surveillance Project

- - Vacant Victorian Healthcare Association

Mr Matt Mason Rural Infection Control Consultant

Ms Alison McMillanManager, Clinical Governance Unit, Office of the Chief Clinical Advisor

Mr Rodney MoranManager, Information and Resources, Communicable Diseases Section

Dr Mike Richards Director

Mr Phil Russo Deputy Director

Prof Denis SpelmanChair, Victorian Advisory Committee on Infection Control Surveillance Sub-committee

Mr Clinton DunkleySenior Program Advisor, Clinical Governance Unit, Office of the Chief Clinical Advisor

Dr Chris McIsaacVictorian Regional Committee - Joint Faculty of Intensive Care Medicine

- - Vacant Epidemiology

Mrs Kylie Berry Secretariat

Appendix 1



Advisory relationship

Reporting relationships Management and administration

Appendix 2

Operating rules

VICNISS Advisory Committee

ProxiesMembers are required to notify the chair or secretariat when there is an intention for a proxy or substitute to represent the member at any advisory committee meeting or to undertake any membership role or responsibility.

AttendanceIf members are unable to attend meetings on three consecutive occasions, the chair will request that a person with equivalent representation replace them.

Declaration of conflict of interestMembers should declare any personal interest at any meeting if it relates specifically to a particular issue under consideration. The secretariat will record this declaration in the minutes.

MediaTo be directed to the Director of VICNISS Coordinating Centre in the first instance.

ConfidentialityUnless stated, all papers are to be viewed as confidential. These are for the exclusive use of the committee members.

Appendix 3



Dr Michael Richards Director Mike is an infectious diseases physician with an interest in hospital-acquired infections and infection prevention. He was previously head of the Infectious Diseases Unit at the Austin and Repatriation Medical Centre and worked as a guest researcher at the Hospital Infections Program at the Centers for Disease Control and Prevention, Atlanta. Mike now works as a physician in the Victorian Infectious Diseases Service and in private practice. He is a member of the National Advisory Board of the Australian Infection Control Association and recently published in the area of epidemiology and intensive care unit acquired infections.

Phil Russo Deputy DirectorPhil has worked as an infection control consultant at the Royal Melbourne and The Alfred hospitals, and was the coordinator of infection control and epidemiology at Southern Health. Phil completed his Masters of Clinical Epidemiology in 2002 and has published several articles on nosocomial infection and surveillance.

Dr Ann Bull Epidemiologist Ann completed a PhD in molecular biology before working for eight years with the federal Environment Department in Canberra and then in Kakadu National Park. She recently completed a Masters in Applied Epidemiology while located at the Australia New Zealand Food Authority in Canberra. Ann has an interest in the application of information technology systems for improving health.

Dr Deb Friedman Infectious Diseases Physician Deb is an infectious diseases physician with an interest in hospital-acquired infections and infection control. She returned from conducting research at Duke University in North Carolina in 2002, and has performed research and published in the area of hospital infections.

Noleen Bennett CNC Infection Control Noleen is one of two senior infection control consultants employed at VICNISS. Previously, she was employed as a senior infection control consultant at Monash Medical Centre. Noleen obtained her Masters in Public Health in 2001 after completing a major critical appraisal of the Department of Human Services’ Guidelines for the classification and design of isolation rooms in health care facilities.

Appendix B: VICNISS Coordinating Centre staff

Claire Boardman CNC Infection Control Claire is one of two senior infection control consultants employed at VICNISS. She has infection control experience in the public and private health sectors, and her last appointment was at Melbourne Health. Claire is completing the Masters of Public Health at Melbourne University, and is the current President of the Victorian Infection Control Professionals Association.

Jane Motley Education Development OfficerJane has extensive education and health care experience in acute, community and public health settings. Her qualifications include a Diploma of Applied Science (Nursing), a Graduate Certificate in Gerontology, a Graduate Certificate in Prom Con, a Graduate Diploma in Education] (Health), and a Certificate IV Assessment and Workplace Training. Jane obtained her Masters of Education in 2003 at Latrobe University.

Simon Burrell Information Technology Support Officer Simon is a Microsoft-certified database administrator and has qualifications in electronics, with experience in the public, community and private business sectors.

Kylie Berry Administrative Assistant Kylie has worked in number of administration-related roles, specifically in the medical industry. Her role involves supporting all VICNISS staff and ensuring they have everything they need to do their job effectively.



References

Australian Infection Control Association Expert Working Group 2001, National surveillance of healthcare associated infection in Australia, Report to the Commonwealth Department of Health and Aged Care, Canberra.

Department of Human Services 2002, Report of the expert working group on surveillance of nosocomial infections, Acute Health, Quality and Care Continuity Branch, DHS, Melbourne.

Haley, R, Culver, DH, Morgan, WM, White, JW, Emori, TG & Munn, VP 1985, ‘The efficacy of infection surveillance and control programs in preventing nosocomial infections in USA hospitals’, Am J Epidemiol, vol. 121, pp. 182-205.

Documents

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