Category Archives: surveillance

Outside the box: Infection prevention beyond the hospital walls

The recent article published in the MJA by Agostino and colleagues from the Hunter New England area provided data that could be described as not so startling, but nevertheless alarming. Their study aimed to identify groups at risk of MRSA infection, as well as the proportion of patients with MRSA but no history of recent hospitalisation (previous 12 months).

In their large cohort, they found that “young people, Indigenous Australians, and residents of aged care facilities, are disproportionally affected by CA-MRSA infections”.

Two comments in their Discussion caught my eye. The authors call for:

  • the focus of control measures to move from the healthcare setting to the community
  • national surveillance of MRSAphotodune-598972-think-outside-the-box-xl

The results of this study are not so startling because the findings are consistent with previous studies, alarming because this is another piece of evidence highlighting the deficits of our local knowledge.

This brings me to my next point. I am excited to be part of a team conducting a large study exploring infection prevention in Australian residential and aged care facilities. Led by Prof Brett Mitchell, together with Prof Ramon Shaban and Dr Deborough MacBeth, we aim to mimic a recent program of work  that generated so much rich information about infection prevention in our hospital facilities. Here are links to a sample of some of papers from this work:

This cross sectional study aims to explore governance, education, practice, surveillance and competency and capability – five key domains relating to infection prevention and control. All aged care homes in Australia are in the process of being contacted.

The findings of this study will be significant, they will:

  • further support ACIPC to refine the role and scope of practice of ICPs and better target education strategies,
  • inform decision-makers faced with accessing and planning infection control resources in settings outside hospitals.
  • guide future research priorities in this area
  • understand priorities and gaps in infection control services

If you receive an invitation to participate, I strongly encourage you to do so.

We look forward to sharing our findings with you during 2018.

Phil

Not peeling grapes…

Standard 3.2.1 of the The National Safety and Quality Health Service Standards in Australia states “Surveillance systems for healthcare associated infections are in place”.

If I could wave the magic wand, the standard I woulrainbow-star-magic-wand-6834-pd like to see would say something like this, “Electronic surveillance systems for healthcare associated infections are in place in alignment with the national surveillance program” (it’s a big wand).

It’s a fact that very few healthcare facilities have dedicated HAI surveillance software, which means that for much of it, surveillance continues to be a manual, labour intensive activity. Not only is this burdensome, we also know it influences data quality. Why don’t we all use electronic surveillance software (ESS)? Capital expenditure aside, maybe its because ICPs (and others) aren’t convinced of their value i.e. what effect does it have on day to day practice, how does it influence the overall infection prevention program?

In a recent systematic review published in the Journal of Hospital Infection, we sought to establish the impact of ESS on infection prevention. We were able to identify 16 papers in a search from 2006 to 2016. The review can be accessed here

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There was much variation in the studies, so it was difficult make any strong conclusions. However, we did find that every paper described a marked reduction in time taken to collect data and ascertain cases. This is clearly a good thing for the ICP collecting data, but I don’t suspect that saved time is spent sitting around peeling grapes. Its possible that the ESS allowed them to broaden their surveillance activities, provide more accurate and better quality data, respond to outbreaks quicker, undertake local research projects,  enable more detailed reports for the clinicians (and less detailed dashboards for their Executives), not to mention standardise data for public reporting and informing the build of algorithms for greater efficiency.

Unfortunately we cant really be sure how an ESS influences (benefits) infection prevention because we don’t have the data. As we conclude in our paper, we need specific research exploring the effect of ESS on infection prevention as a primary outcome, and whether this has any impact on infection and /or patient outcomes.

It would be very interesting to know if any hospitals with ESS have explored this issue, or if those who are moving towards implementing an ESS have considered some metrics around the benefits.

– Phil

The burden of HAIs in Australia

Today, we published an article in Infection, Disease and Health estimating the number of HAIs occuring in Australia each year. [1]

To do this, we undertook a systematic review of the peer reviewed literature between 2010 and 2016. We identified 24 articles that reported the incidence of HAIs in Australian hospitals.

Overall, data from these multi centred studies suggested 83,000 HAIs per year in Australia. UTIs are were the most common, followed by C.difficile, SSIs, respiratory infections and Staphylococcus aureus bacteraemia. HAI burden.png

Of course, these numbers are a very  large underestimate given the lack of or incomplete data on common infections. It is also limited to data published in the peer reviewed literature.

Incidence data on infections such as pneumonia, gastroenterological and bloodstream infections (other than SAB) were not identified, thus potentially
missing up to 50% of infections. That being the case, the

PPS blog incidence of HAIs in Australia may be closer to 165,000 per year.

Don’t believe me? Have a look at the results of point prevelance studies in Europe (right). Respiratory tract infections, bloodstream infections and others account for a large proportion of HAIs.  Of course, Australia has not had a PPS undertaken in 30 years, so we don’t really know. However, for readers of this blog, you will know that will soon change.

A figure of 200,000 HAIs per year in Australia is commonly cited, however, this figure was derived from one study undertaken several years ago (a sign of what was available at the time). Our study, may, in part, demonstrate the increasing number of publications on HAIs in Australia. We are certainly not suggesting a reduction in HAIs and any such claim based on the findings of our study should be immediately dismissed.

There are some other equally important findings from our study:

  • There needs to be a determination and action by state and national government bodies to achieve consensus on national HAI definitions
  • We need national approaches to HAI surveillance and transparent regular reporting. Australia is so far behind other countries in this regard [2] [3]
  • In the absence of action by government, we call on those undertaking HAI surveillance (especially incidence) to report your data in the peer reviewed literature

We also found there is little information about healthcare associated respiratory infections, such as pneumonia. Maybe it is in the too hard basket (nice blog by Martin Keirnan which says it all). Well, I think we should do something about healthcare associated pneumonia – at the very least, understand the incidence and risk factors a little better. I am working on it…..

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Footnote: Some of the research I have been involved with has been supported by donations from the public. For that, I am very grateful. Should you or your company wish to make a tax deductible donation, you can do so here.

References

  1. Mitchell, BG., Shaban, R., MacBeth, D., Wood, CJ., Russo, PL (2017). The burden of healthcare-associated infection in Australian hospitals: A systematic review of the literature. Infection Disease and Health. https://doi.org/10.1016/j.idh.2017.07.001
  2. Russo, P. L., Cheng, A. C., Richards, M., Graves, N., & Hall, L. (2015). Healthcare-associated infections in Australia: time for national surveillance. Australian Health Review, 39(1), 37-43.
  3. Russo PL, Cheng AC, Mitchell BM, & L, H. (2017). Healthcare associated infections in Australia – Tackling the “known unknowns”! Australian Health Review, (published online 7 March 2017), http://dx.doi.org/10.1071/AH16223

 

Australian HAI Point Prevalence Study is Coming

Followers of this blog will know how passionate Phil Russo and Brett Mitchell are about the need for national surveillance and a point prevalence study (PPS). Map Aus2We are very pleased to let you know that a HAI PPS is coming, by way of a research project.

For more information, please see www.ipcca.com.au/pps

 

 

Next national HAI initiative – CAUTI of course #ACICP conference

To conclude the ACIPC conference in Melbourne this year, three different views were proposed for what the national national HAI initiative should be. Dr Phil Russo presented a case for national surveillance, while Prof Linsday Grayson presented a case for peripheral vascular devices. I had the job of presenting a case for CAUTI.

The debate allowed 15 mintes each for us to present, followed by a panel discussion, discusion and questions from the floor, in addition to questions from Twitter (for those not present but following online).

Following some great questions, humour and some lively discussion, in the end, Phil won the debate, with 50%, followed by peripheral vascular devices (30%) and CAUTI (20%). It was clear however, that all three projects had debatesupport and it was strongly suggested that all three be implemented with the next 5 years.

I did make a good come back, scoring up from a prepoll of 6%!

If you would like to see the CAUTI presentation I delivered, here it is: ACIPC presentation: Next national HAI Initiative, CAUTI or in pdf format here

Brett

Disclosure: BM was the Scientific Chair or ACICP 2016, PR was on the scientific committee.

 

What do we know about antimicrobial use in Australian residential aged care facilities?

The National Centre for Antimicrobial Stewardship (NCAS) is a multidisciplinary collaborative funded by the NHMRC with a strong track record of innovation and Capturesuccessful translation into clinical practice. We asked Dr Noleen Bennett from NCAS to write about a national antimicobial prescribing survey in aged care. It has brought up some interesting findings.

Thanks for Noleen for this blog – Phil, Brett and Ramon.

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The short answer is we know antimicrobial use in Australian residential aged care facilities (RACFs) needs to be improved. The unacceptable risk otherwise is the emergence of multi drug resistant infections and other adverse consequences in this vulnerable population.

In 2015, 186 RACFs participated in the pilot Aged Care National Antimicrobial Prescribing Survey. Key areas for improvement were identified and included:

  • inadequate documentation
    • 31.6% of prescriptions did not have an indication justifying their use
    • 65.0% of prescriptions did not have a review or stop date documented.
  • the use of antimicrobials for unspecified skin infections
    • 17.5% of antimicrobials were being used for unspecified skin infections.
  • prolonged duration of prescriptions.
    • 31.4% of prescriptions had been prescribed for longer than six months.

All Australian RACFs and multi-purpose services are now strongly encouraged each year to participate in acNAPS. Participation assists in ensuring compliance with national guidelines and targeting local and national actions to support appropriate antimicrobial use.

For further information, the friendly NAPS team can be contacted via email support@nasp.org.au or phone (03) 9342 9415. The data collection period for the 2016 acNAPS has been extended. Data can now be collected and entered prior to Friday 9th September.

Declaration: Dr Noleen Bennett is employed at the National Centre for Antimicrobial Stewardship and is the Project Officer for the Aged Care National Antimicrobial Prescribing Survey

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Brett: For those interested in other Australian data in residential and aged care (infection and antimicrobials related) here are some links to articles. (This is not an exhaustive list)

 

 

What does the evidence say?

The Australian Commission for Safety and Quality in Health Care has recently developed 16 “Hospital acquired complications” (HACs) that have been published on their website.

Whilst the website provides information on the development of these HACs, it does not specifically detail their purpose. One of the 16 HACs is “Healthcare Associated Infection”, which is comprised of eight different HAI “diagnoses”, including “multiresistant organisms” and “gastrointestinal infections”.

There is clear evidence, both locally and internationally, that coding data does not accurately identify HAIs, and any attempt to do so would misrepresent the truth.

Successful infection prevention efforts rely on valid data. If the data are not accurate, then not only do we run the risk of misdirecting interventions and misinterpreting the outcome of interventions, we are also wasting precious resources.

It is a wonder why, in this field where so often we don’t have good evidence for certain practices, that when good evidence does exist, it still does not seem to influence policy and practice.

Phil

Declaration: Philip Russo is a member of the ACSQHC HAI Advisory Committee.