A Proposal to Control Nosocomial Blood Stream Infections In The by gabyion


									    Nosocomial Infections
Epidemiology and key concepts

         Nelly Hassan Ali ElDin
             Department of
   Cancer Epidemiology & Biostatistics
 Nosocomial infection:
It is an infection acquired in a medical
  setting in the course of medical treatment.
  It meets the following criteria:
• 1 - Not found on admission
• 2 – Temporally associated with admission or
  a procedure at a health-care facility
• 3 – Was incubating at admission but
  related to a previous procedure or
  admission to same or other health-care
 Why Nosocomial infection ?
It is an important public health problem because of
  their   frequency,    attributable morbidity   and
  mortality and cost. In the USA and in Europe,
  approximately 5–10% of hospitalized patients
  develop an infection during their hospital stay.
  Higher incidence rates are reported in hospitals in
  developing countries.

In our hospital (National cancer Institute,), blood
  stream   infections   among   pediatric   patients
  accounted for 87.6/1000 discharges at 1999).
  Hospital acquired infection HAI contributed to
  37.5% of these episodes.
Monthly incidence of febrile episodes and associated
 BSI rates per 1000 discharges in the pediatric
  inpatient units from January to December 1999

                               700                                            Febrile episodes
       Rate / 1000 discharge

                               600                                            BSI















 Impact of nosocomial infection?
• Increased morbidity (serious consequences and
  permanent disability )
• The length of hospital stay is prolonged, on average
  by 5–10 days.
• The risk of death approximately doubles in patients
  who acquire hospital infection.
• Hospital-acquired infections are very expensive and
  contribute significantly to the escalating costs of
  health care. It has been argued that, even if
  moderately effective, a hospital infection control
  program is one of the most cost-effective and
  cost-beneficial preventative medical interventions
  currently available.
Definition of Nosocomial infection
The use of uniform definition is crucial if data from one
  hospital are to be compared with those of another hospital
  (inter-hospital) or with an aggregated database (intra-
NI is a localized or systemic condition:
1- that results from adverse reaction to the presence of an
  infectiuos agent(s) or its toxins and
2- that was not present or incubating at the time of admission
  to the hospital.
For most bacterial NI, it become evident 48 hours or more
  (typical incubation period) after admission. Because the
  incubation period varies with type of pathogen, and extent of
  the underlying condition, each infection should be assessed
  individually for evidence that links it to hospitalization.
  Specific situations of NI
In superficial incisional surgical site infections
  (SSI) which involve only the skin or
  subcutaneuos tissues, it occurs within 30
  days after the operation.
In deep incisional SSI which involves deep soft
  tissues (fascia and muscles) and organ/space
  SSI which involves anatomic structures not
  opened or manipulated during operation, in
  both conditions; it occurs 30 days of
  operation or within one year if an implant is
Important principles upon which NI
definitions are based
First (available information):
The information used to determine the presence and
  classification of an infection should be a combination of
  clinical findings, laboratory evidence and supportive data.
  Clinical evidence is derived from direct observation of the
  infection site or review of other pertinent sources of data
  such as the patient‟s chart or medical record.
  Laboratory evidence includes results of cultures, antigens or
  antibody detection or microscopic examination.
  Supportive data are derived from other diagnostic studies
  such as: X-ray, US, CT, MRI, BAL, Endoscopy, ..etc
Second, (a physician‟s or surgeon‟s diagnosis)
The diagnosis of infection by the surgeon or
  physician is derived from direct observation during
  a surgical operation, endoscopic examination or
  other diagnostic study or from clinical judgment.
  This diagnosis could be an acceptable criterion for
  an infection unless there is compelling evidence to
  the contrary.
For certain sites of infections, however, a
  physician‟s clinical diagnosis in the absence of
  supportive data must be accompanied by initiation
  of appropriate or empirical antimicrobial therapy
  to satisfy the criterion.
There are two special situations in which an infection is
   considered nosocomial:
a) Infection that is aquired in the hospital but does not become
    evident until after hospital discharge.
b) Infection in a neonate that results from passage through the
    birth canal.
There are two special situations in which an infection is not
   considered nosocomial:
a) Infection that is associated with a complication or extension
   of infection already present on admission, unless a change in
   pathogen or symptoms strongly suggests the acquisition of
   new infection.
b) In an infant, an infection that is known or proved to have
   been acquired transpalcentally (e.g congenital rubella,
   toxoplasmosis) and become evident at or before 48 hours
   after birth
There are two conditions that are
not infections:
1) Colonization, which is the presence of
  microorganisms        (on    skin,    mucous
  membranes, in open wounds or in
  execretions or secretions) that are not
  causing clinical signs or symptoms. .
2) Inflammation, which is a condition that
  results from tissue response to injury or
  stimulation by noninfectious agnets such as
There are two additional points that are important to
  understand regarding the definition of NI:
Fisrt) the preventability of an infection is not a
   consideration when determining whether it is
For example, preventing the development of
   nosocomial C. difficle pseudomembraneous colitis
   after extensive antibiotic treatment may not be
   possible (i.e inevitable in some immunocompromised
Another example some would argue that neonatal
  infections acquired during vaginal delivery are
  inevitable and, therefore, should not be counted as
However,    these     neonatal     infections   are
  nosocomial, they can be identified as
  maternally acquired, and the analysis of their
  incidence can be dissiminated to obestetricians
  for interventional strategies (i.e preventable).

Second), surveillance definitions are not intended
  to define clinical disease for the purpose of
  making therapeutic decisions. Some true
  infections (HIV infection) will, therefore, be
  missed while other conditions (asymptomatic
  bacteruria) may erroneously be counted as
    Goals for infection control and
    hospital epidemiology
There are three principal goals for hospital
   infection    control   and     prevention
1. Protect the patients
2. Protect the health care workers,
   visitors, and others in the healthcare
3. Accomplish the previous two goals in a
   cost effective and cost efficient
   manner, whenever possible.
    Function and organization of the
       infection control program
The provision of an effective infection control program
  (ICP) is a key to the quality and a reflection of the
  overall standard of care provided by the health care
Major differences among countries in their health care
 resources and organization, and medical cultures explain
 the diversity of approaches to the organization of
 hospital hygiene and infection control programs.
The growth in ICP has been paralleled by the
  establishment and growth of a number of professional
  and governmental organizations which focus on NI
  prevention and control such as (APIC, SHEA, CDC,
  Infection control program
In the majority of countries ICP,
  typically operates on two levels: an
  executive body – the infection control
  team (ICT) – and an advisory body to
  the hospital management – the infection
  control committee (ICC) – which adopts
  the „legislative‟ role of policy making.
Infection Control Committee
Infection control Committee (ICC):
The hospital ICC is charged with the responsibility
  for the planning, evaluation of evidenced-based
  practice and implementation, prioritization and
  resource allocation of all matters relating to
  infection control.
The ICC must have a reporting relationship directly
  to either administration or the medical staff to
  promote ICP visibility and effectiveness. The
  ICC should meet regularly (monthly) according to
  local need
Infection Control Committee (cont):
The membership of the hospital ICC should reflect the
   spectrum of clinical services and administrative
   arrangements of the health care facility. As a minimum,
   the committee should include:
1.   Chief executive, or hospital administrator or his/her
     nominated representative.
2.   ICD or hospital microbiologist (chairperson).
3.   Infection Control Nurse (ICN).
4.   Infectious Diseases Physician (if available)
5.   Director of nursing or his representative.
6.   Occupational Health Physician (if available).
7.   Representative from the major clinical specialities.
8.   Additionally representatives of any other department
     (pharmacy, central supply, maintenance,
     housekeeping…etc) may be invited as necessary
The ICC has the following tasks:
•   To review and approve the annual plan
    for infection control
•   To review and approve the infection
    control policies.
•   To support the IC team and direct
    resources to address problems as
•   To ensure availability of appropriate
•   To review epidemiological surveillance
    data and identify area for intervention.
    The ICC has the following tasks (cont):
•    To assess and promote improved practice
     at all levels of the health care facility
•    To ensure appropriate training in infection
     control and safety.
•    To review risks associated with new
     technology and new devices prior to their
     approval for use.
•    To review and provide input into an
     outbreak investigation
•    To communicate and cooperate with other
     committees with common interests such as
     antibiotic committee, occupational health
Infection Control Team (ICT):
It comprises the infection control doctor
  ICD and infection control nurse ICN.
  The ICT is responsible for the day-to-
  day running of ICPs. It is important that
  all hospitals should have an ICT. The
  optimal structure of ICT will vary with
  needs and resources of the facility. The
  ICT must have the authority to manage
  an effective ICP. In large hospitals, this
  usually    means    a    direct   reporting
  relationship with senior administration
Role of Infection Control Team :
The role of ICT is to:
Ensure that an effective ICP has been
  planned, co-ordinate its implementation,
  and evaluate the impact of such
It is important to ensure that there is a
  24-hour access to the ICT for advice on
  infection prevention and control which
  would include both medical and nursing
The role of Infection Control Team :
• To develop an annual infection control plan with
  clearly defined objective.
• To develop written policies and procedures
  including regular evaluation and update.
• To supervise and monitor daily practices of
  patient care designed to prevent infection.
• To ensure availability of appropriate supplies
• To organize an epidemiological surveillance
  program (particularly in high risk areas for early
  detection of outbreak).
• To educate all grades of staff in infection
  control policy, practice and procedures
The Role of Infection Control Team (cont):
• To develop and implement annual training plan for
  all health care workers.
• To have scientific and technical support role in
  purchasing and monitoring of equipment and
• To participate with the pharmacy and antibiotic
  committee in developing a program for
  supervising the use of antibiotics.
• To participate in the audit activity.
• To submit monthly reports on activities to ICC.
Infection Control Doctor (ICD):
 Infection Control Doctor (ICD):
The infection control physician should be a
  medically qualified senior staff of the
  facility who is interested in and who spends
  the majority of his time involved in hospital
  infection control.
He could be a medical microbiologist, an
  epidemiologist or infectious disease physician
Irrespective of his professional background,
  the ICD should have the interest, knowledge
  and experience in different aspects of
  infection control.
The role and responsibilities of the ICD:
• Serves as a specialist advisor and takes a leading
  role in effective functioning of the ICT.
• An active member of ICC may be the chairman.
• Assist the ICC in drawing the annual plan, policies
  and long-term program for prevention & control of
  hospital infection.
• Advises the hospital administrator directly on all
  aspects of infection control
• Participates in the preparation of tender documents
  for support services
• Must be involved in setting quality standards,
  surveillance and audit with regard to hospital
Infection Control Nurse (ICN)
  Infection Control Nurse (ICN)
An ICN or practitioner is a registered nurse
 with an additional academic education and
 practical training which enables her to act
 as a specialist advisor in all aspects relating
 to infection control.
The ICN is usually the only full-time
 practitioner     in the ICT and therefore
 takes the key role in day-to-day infection
 control activities with the ICD providing the
 leading role
   The role of Infection Control Nurse
The role and responsibilities of the ICN are
   summarized as follows:
 Has an ongoing contribution to the development
   and implementation of IC policies and procedures,
   participate in auditing and monitoring tools
   related to IC and infectious diseases.
 Provide     specialist    nursing  input   in  the
   identification, prevention, monitoring and control
   of infections within the hospital
 Participate     in    surveillance  and   outbreak
The role of ICN (cont)
 Identify, investigate and monitor infections,
  hazardous practice and procedures
 Participate in the preparation of documents
  relating to service specifications and quality
 Participate in training and educational
  programs and in membership of relevant
  committees where infection control input is
How to achieve in infection control
Infection control is a quality management
A. Quality is defined by its attributes:
   effectiveness,     efficiency,     optimality,
   acceptability,   legitimacy,    and    equity.
   Quality is also the relationship of
   structure, process and outcome.
B. Quality is “hassle elimination”
C. Quality is the result of planning, monitoring
   (through measurement) and improvement
   (through team effort)..

     Scientific           Teamwork
      approach         (Joiner traingle)
  Improvements in quality are achieved by
understanding processes, and variations and
 are supported by teamwork and scientific
Thank you

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