Malaysian National Nosocomial Infection Surveillance System - DOC by cjk47898

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									Malaysian
National
Nosocomial
Infection
Surveillance
System
WHO Mission Report

Mary-Louise McLaws
Executive summary

The original mission objectives and actions to be undertaken by 31 August 2007 (Annex 1)
were modified by the Ministry of Health and listed below:


Objective 1.   To advise on the development of a Malaysian National Nosocomial
               Infection Surveillance System (to include surveillance of the following
               multiple resistant micro-organisms (MROs): MRSA, ESBL & Klebsiella).


Objective 2.   To advise on methods for enhancing the hand hygiene programme.


Objective 3.   To engage in discussions with the Ministry of Health staff on the contents of
               the workshop.


Objective 4.   To provide training in Hospital Epidemiology to Ministry of Health staff.


Objective 5.   To advise on surveillance strategies for the control of Methicillin Resistant
               Staphylococcus aureus (MRSA) (based on Australian experience).


Table 1 outlines each objective, in the order of action, and the associated actions:
Table 1 Overview of the Objectives, the Order and the Action related to each Objective
 Objectives                     Order    Action

 3. To engage in discussion       1      Discussions were held with Dr Mohd. Shah bin Dato Idris, Dr Razaini biti Mohd
 with MOH staff on the                   Zain (Deputy Director Quality of Medical Care Section) and Dr HJH Kalsom biti
 content of the workshop                 Maskon about the present surveillance and reporting system. Suggestions for
                                         modifications to the twice yearly prevalence survey for healthcare associated
                                         infection (HAI) indicators, continuous surveillance of MRSA and ESBL and rapid
                                         analytical method for MROs were discussed with MOH prior to the surveillance
                                         workshops. It was decided that the Hospital Epidemiology workshop be
                                         postponed to provide more time to discuss surveillance at the workshop with the
                                         key Infection Control stakeholders. The Hospital Epidemiology workshop was
                                         given in August/September (held in Kota Kinabalu) and included an in-depth
                                         skills-based workshop on rapid analysis of MRO surveillance data using Process
                                         Control Chart (PCC) Statistics.
 1. To advise on the              2      After visits to hospitals and discussions with MOH, MLM presented to MOH and
 development of a Malaysian              participants at the surveillance workshop (held in Langkawi) the
 Nosocomial Infection                    advantages/disadvantages of the present system and suggested modifications
 Surveillance System                     including: streamlining the twice yearly surveys, modifying the method of
                                         calculating rates, adding IC process indicators (e.g. hand hygiene audits and
                                         antibiotic prescribing audits), and improving the timeliness of reporting of MROs.
 4. To provide training on        3      A workshop on surveillance methodologies and MRSA control was given instead
 Hospital Epidemiology                   of Hospital Epidemiology. As a consensus building consultation exercise, the IC
 (national surveillance and              staff were informed about the advantages/disadvantages of numerous
 NNISS) to MOH staff                     surveillance methodologies before they formed into small focus discussion
                                         groups to review their local and national needs of a surveillance system. A wider
                                         discussion was then led and consensus was reached for inclusions and
                                         exclusions of indicators, methodology and a new method of analysis and
                                         reporting MROs monthly using PCC statistics.
 5. To advise on surveillance     4      Consultations with the key IC staff included discussions about their present
 strategies for control of               MRO-related IC practices and international practices such as targeted screening
 MRSA                                    programme and dedicated nurses for the care of MRSA infected patient who
                                         does not simultaneously care for non infected MRSA patients (referred to as
                                         cohort nursing). Benefits of rapid analysis and reporting of MRSA infection using
                                         PCCs were presented with illustrations of monthly charts used to evaluate MRO
                                         control and management strategies.
 2. To advise on methods to       5      A lecture at the Melaka and Putrajaya hospitals and at the surveillance
 enhancing the hand hygiene              workshops was given on international hand hygiene campaigns, the WHO Clean
 programme                               Hands Saves Lives campaign and research on healthcare worker’s human and
                                         organisational behaviour affecting compliance. Modifications to the planned
                                         Malaysian campaign were presented that included an overt hand hygiene audit
                                         during the twice yearly prevalence surveys with a two-week preparation where
                                         staff choose their hand hygiene “buddy” to remind each other to comply with
                                         hand hygiene. This two-week preparation period would act to educate clinicians
                                         about correct practice as well as to change social norms towards an acceptance
                                         of being asked to hand hygiene.
 4. To provide training on        6      An Introductory Hospital Epidemiology workshop was given in
 Hospital Epidemiology                   August/September, located in Sabah, that included an in-depth skills-based
 (national surveillance and              workshop on special analytical skills for MRO surveillance and control.
 NNISS) to MOH staff




                                                                                                                     ii
Actions:

Visit 1. Email discussions with the Ministry of Health (MOH) resulted in the original terms
of reference (Annex 1) being modified (Annex 2). The time frame (Annex 3) remained
according to previous arrangements. During face-to-face discussions, the MOH was
advised that Objective 4 (To provide training on Hospital Epidemiology to MOH staff)
should be replaced with the original Objective 2 (To conduct a national workshop and
training on healthcare acquired infections and NNISS) and that I would return to Malaysia
to provide a workshop on Hospital Epidemiology at a later date.



Lectures on surveillance methodologies were given at Melaka and Putrajaya hospitals with
the aim of introducing the MOH clinical staff to the experiences of surveillance in Australia
and overseas surveillance systems (Annexes 4 and 5). The local IC problems were
discussions and the advantages and disadvantages the Malaysian system to address
these issues were discussed.



Two surveillance workshops were given separately to nurses and microbiologist/infectious
diseases physicians, each 1.5 days in duration. The workshops included lectures and
overviews of surveillance systems, the advantages and disadvantages of the different
surveillance systems and the requirements of data and its analysis to manage the spread
of MROs (Annexes 4 and 5). Participants at the surveillance workshop were then formed
into small focus discussion groups to consider a list of questions (Annex 6) about the
usefulness of the current surveillance system (Table 2a), what they would like changed or
continued, and to evaluate several strategies aimed at reducing MROs and to increase
hand hygiene. Each discussion group presented their answers (Annex 7 Nurses, Annex 8
Doctors). An aggregation of answers was presented and discussed (Annex 9 Nurses and
Doctors).   Discussion resulted in a consensus for the components of a new national
surveillance system. Participants were also introduced to a new method of analysis, called
process control statistics which can produce monthly charts illustrating the endemicity of
MROs plotted against a predetermined threshold for evaluation of control strategies
(Annex 10).




                                                                                          iii
       Results:

       Table 2a summarise the current surveillance programme while Table 2b presents the
       modifications to the components of the current programme, including the removal
       and additions of indicators.



Table 2a. Old components of surveillance                  Table 2b. New components of surveillance

Continuous surveillance for MRO Control:                  Continuous surveillance for MRO Control
                                                           MRSA and ESBL infection (all positive blood cultures
 MRSA & ESBL from blood cultures and swab
                                                              associated with infection)
    cultures
                                                           Plot bloodstream infections on process control charts for
                                                              monthly analysis and monthly feedback to ward staff
                                                           Report per 10,000 occupied bed-days
                                                           antibiogram
                                                           Selected pilot sites to send in first 100 staphylococcus
                                                              aureus infection isolates from blood cultures to reference
                                                              lab for typing & antibiogram for MRSA/MSSA, invasive
                                                              infection (yes/no), age of patient.
Bi-annual prevalence survey -Outcome Indicators:
                                                          Bi-annual prevalence survey – Outcome Indicators:
 All clean surgical procedures (stratified by level of    Targeted surgical procedures (hospital’s choice of
     infection: soft tissue, deep, organ space)                commonly performed). Rates calculated in accordance
 Ventilator associated pneumonia                              with international methods and stratified by level of
 Bloodstream Infection from swabs & blood culture             infection.
 Clinical Sepsis                                          CVL-Related Bloodstream Infection in ICU patients at
                                                               large hospitals
 Urinary Tract Infections
 Gastrointestinal Infections
 Aggregate of all other infections


Bi-annual prevalence survey - Process Indicators
                                                          Bi-annual prevalence survey - Process Indicators
     nil                                                 • Targeted antibiotic usage (collect reason for usage &
                                                               Defined Daily Dose (DDD) for specific antibiotics e.g. 3rd
                                                               generation cephalosporins & vancomycin)
                                                          • Hand Hygiene compliance audit
                                                          • Prophylaxis for targeted surgical procedures (limited
                                                               dataset as a flag of compliance e.g. Did patient receive
                                                               prophylaxis Yes/No)
                                                          • Peripheral Line in situ duration (limited dataset as a flag
                                                               of compliance e.g. Was line in situ for ≤ 72 hours/
                                                               >72hours)
                                                          • Removal CVL on discharge from ICU (limited dataset as a
                                                               flag of unnecessary use e.g. Was ICU patient discharged
                                                               with CVL in situ to ward Yes/No)




       At a follow-up meeting with the MOH after the workshop the new approach, outlined
       in Table 2b, was discussed as well as the inclusion of a rapid analysis of MRO

                                                                                                                       iv
endemicity using Process Control Chart (PCC) statistics. The PCC method is not
slow to develop a rate for each MRO because it can analyse a small dataset (e.g.
separately for ICU or sentinel ward) monthly. The MOH can also continue to
calculate an annual rate of MROs expressed per 10,000 occupied bed days. The
monthly PCC analysis of MROs allows for the endemic level to be reported back to
staff in a more real-time frequency and the ward and IC staff can continuously
evaluate their control strategies.



The MOH requested a second visit to train key IC staff on this proposed analytical
technique.



Visit 2. A request was made by the MOH for me to attend the Asia Pacific Society for
Infection Control (APSIC) Congress to provide a key note address and present a
workshop on PCC statistics after closure of the Congress. The MOH representative
was informed that I was required to be in Sydney immediately after the closure of the
Congress and could not stay to give a workshop. The MOH requested I still attend
the Congress to presentation a paper on the management and behavioural issues
related to infection control (Annex 11).

Result:

A talk on the behavioural and management aspects of infection control was
presented at the APSIC congress. A third date for the workshop on PCC statistics
was 27-30 August.



Visit 3. An Introductory Hospital Epidemiology (Annex 12) workshop, held in Kota
Kinabalu, Sabah, was given to microbiologists and infection control practitioners from
Sabah and Sarawak. This workshop focused on PCC statistics and interpretation for
the control of MROs (Annex 8). Participants were introduced to the concept of the
effects of random variation on rates using an arithmetic mean of MRO infections and
how the Exponentially Weighted Moving Average (EWMA) statistics controls for the
effect of random variation. Statistical discussions involved the problems of false
positive alarms (caused by rates affected by random variation) and false negative
alarms (caused by too frequent analysis of rare event data that can produce
inaccurately low rates). Participants were given an Excel spread sheet with pre-
programmed calculations (Annex 9) to enter their own data and produce a PCC.

                                                                                         v
Result: Microbiologists and Infection Control Practitioners at the Sabah workshop
learnt about the process control chart calculations, plotting data and interpreting the
chart statistics. The participating gained skills in:

               Understanding the difference between arithmetic means of infection
                and the PCC Exponentially Weighted Moving Average statistics

               Choosing a threshold for each MRO infection (this is a crucial step as
                this is utilised in the Exponentially Weighted Moving Average
                statistics)

               The interpretation of the Exponentially Weighted Moving Average
                (EWMA) statistic

               Using the PCC statistics to develop an appropriate strategy to control
                MROs.




                                                                                          vi
Table of Contents


                                                     Page

Executive Summary                                    i

Table Contents - Tables                              viii

Index of Attachments of Annexes                      ix

Purpose of mission                                   1

Activities and Findings in Sequential Order
                                                     2
                                Objective 3
                                                     7
                                Objectives 1
                                                     9
                                Objectives 4
                                                     13
                                Objective 5 and 2
                                                     15
                                Objective 4


Conclusion and Recommendations

                                Objective 3          16

                                Objectives 1         19

                                Objectives 5 and 2   27
                                Objective 4          30



Acknowledgements                                     31

Attachments of Annexes




                                                            vii
Index of Tables


Table    Title                                                                                        Page


1        Overview of the Objectives, the Order and the Action related to each Objective               ii


2a       Old components of surveillance                                                               iv


2b       New components of surveillance                                                               iv


3a       Point prevalence rate of six healthcare associated infections expressed as a proportion of   3
         all HAI surveyed


3b       Point prevalence rate for all healthcare associated infections by hospital expressed as a    4
         rate by number of patients surveyed.


3c       Point prevalence rate of surgical site infection by anatomical level of infection            5


4a       Deletions from the current surveillance system                                               25


4b       Modifications and additions to the current surveillance program                              26




                                                                                                           viii
Index of Attachments of Annexes


Annex     Title


1         WHO Original Terms of Reference


2         Modified Terms of Reference and Time Frame by MOH


3         Time frame for Mission in National Surveillance of Hospital Infection for Malaysian Ministry of
          Health


4         Surveillance Lecture - PowerPoint

5         Hand Hygiene Lecture – PowerPoint

6         Focus Discussion Prompts for Doctors and Nurses to identify perceived weaknesses and
          strengths of current surveillance system

7         Nurses’ Focus Group Discussion Findings prior to Consensus

8         Doctors’ Focus Group Discussion Findings prior to Consensus

9         Nurses’ & Doctors’ Consensus on the New Surveillance System

10        Screening protocols for the control of MROs

11        Introduction to Process Control Charts Lecture - PowerPoint

12        Asia Pacific Society for Infection Control (APSIC) Congress Changing Human Behaviour (and
          Infection Control) Lecture - PowerPoint

13        Introduction to Hospital Epidemiology Lecture – PowerPoint


14        Understanding and Producing Process Control Chart Analysis Lecture - PowerPoint


15        Excel Spread Sheet with Process Control Statistics for Chart Production




                                                                                                            ix
Purpose of mission

Objective 1. To advise on the development of a Malaysian National
                 Nosocomial Infection Surveillance System (to include MRSA,
                 ESBL & Klebsiella surveillance).


Objective 2. To advise on methods for enhancing the hand hygiene programme.


Objective 3. To engage in discussions with the Ministry of Health staff on the
                 contents of the workshop for national surveillance.


Objective 4. To        provide     training on        Hospital   Epidemiology (National
                 Surveillance and NNISS) to Ministry of Health staff.


Objective 5. To advise on surveillance strategies for the control of Methicillin
                 Resistant Staphylococcus aureus (MRSA).




Malaysian National Nosocomial Infections Surveillance System                              1
Activities (in sequential order) and Findings

Objective 3. To engage in discussions with the Ministry of Health staff on the
content of the workshop for national surveillance.


Activity 1. Participated in discussions with the MOH staff, Dr Mohd. Shah bin Dato Idris,
Dr Razaini biti Mohd Zain (Deputy Director Quality of Medical Care Section) and Dr HJH
Kalsom Biti Maskon about the NNISS. The MOH presented the content of the current
surveillance system and the consultant suggested modifications to the current approach
that were to be further discussed with hospital IC staff at the hospital visits and workshops.
The content of the lectures for two hospital visits and the structure two surveillance
workshops (located in Langkawi) were discussed.


Findings 1.1 As clinicians could not spend large amounts of time away from their hospital
work the duration of the workshops was to be short. Therefore, after discussions with the
MOH it was decided that rather than giving lectures on Hospital Epidemiology, the
workshop should be a forum for key stakeholders to engage in discussions with the WHO
consultant about the restrictions and benefits of the current national surveillance and to
discuss and gain cooperation for the suggested changes and modifications (Annex 4).


Findings 1.2 The surveillance workshop should discuss the current national surveillance
system, the advantages and disadvantages and an overview of other methodologies.
Initial findings of the shortfalls in the surveillance methodology for all seven healthcare
associated infections (HAI) indicators should be discussed at the workshop and are as
follows:
     Twice yearly prevalence surveys collecting data on urinary tract infections (UTI),
     bloodstream infections, ventilator associated pneumonia (VAP), clinical sepsis,
     surgical site infection (SSI) by level of infection (superficial skin, soft tissue, and deep)
     and Other (Other) healthcare associated infections reported as an aggregate.
              o   These data were used to estimate point prevalence rates of infection for six
                  HAI and expressed as a proportion of the total HAI surveyed (Table 3a
                  taken from MOH Report):
           HAI                X 100
           Total Number HAI




Malaysian National Nosocomial Infections Surveillance System                                    2
     Table 3a Point prevalence rate of six healthcare associated infections expressed as a
     proportion of all HAI surveyed.
     Healthcare Associated Infection           Number of cases               Percentage
     Urinary Tract Infection                          37                      8.56 %
     BSI                                              71                     16.44 %
     Pneumonia                                       104                     24.07 %
     Clinical Sepsis                                  54                      12. 5 %
     Surgical Site Infection                         108                       25 %
     Surgical Site Infection
         a. Skin                                      29                      6.71 %
         b. Soft Tissue                               58                     13.43 %
         c. Deep                                      21                      4.86 %
     Other                                            58                     13.43 %
     TOTAL                                           432                      100 %


             o    A point prevalence rate for all healthcare associated infections for each
                  hospital is calculated as a proportion of the total number of patients
                  surveyed (Table 3b, taken from MOH report):


                       HAI                                     X 100
                       Total Number Patients Surveyed




Malaysian National Nosocomial Infections Surveillance System                                  3
     Table 3b Point prevalence rate for all healthcare associated infections by hospital expressed as a
     rate by number of patients surveyed.
     Hospital                              Total number of      Number of Nosocomial       Percentage (%)
                                               patients             infection cases
                                                 265                       10                   3.8%
                                                617                      16                   2.59%
                                                825                      23                    2.8%
                                                689                      24                   3.48%
                                               1793                      70                    3.9%
                                                857                      16                   1.87%
                                                553                      17                    3.1%
                                                656                      21                   3.20%
                                               1045                      14                   1.33%
                                                585                      14                    2.4%
                                                557                      13                   2.33%
                                                587                      15                   2.55%
                                                626                      36                   5.75%
                                                662                      40                   6.04%
                                                 -                        -                      -
                                                564                      40                   7.09%
                                                731                      63                   8.61%
     TOTAL                                     11612                    432                   3.72%


SSIs are also calculated as counts stratified by anatomical level of infection by hospital
(Table 3c taken from MOH Report).




Malaysian National Nosocomial Infections Surveillance System                                                4
     Table 3c. Point prevalence rate of surgical site infection by anatomical level of infection
     Hospital Name                   SSI                 SSI                 SSI              Total SSI
                                 Soft Tissue            Deep               Organ
                                      -                   1                   1                     2
                                      -                   3                   1                     4
                                      2                   3                   4                     9
                                      -                   2                   -                     2
                                      -                   5                   1                     6
                                      -                   2                   -                     2
                                      2                   4                   -                     6
                                      -                   8                   -                     8
                                      -                   3                   1                     4
                                      3                   3                   2                     8
                                      2                   4                   -                     6
                                      -                   -                   3                     3
                                      3                   2                   5                    10
                                     10                   5                   0                    15
                                      -                   -                   -                     -
                                      4                   5                   3                    12
                                      3                   8                   0                    11
     Total                           29                  58                  21                    108


     Continuous surveillance of MRSA and ESBL from positive blood and swab cultures
     and presented as rates per 100,000 admissions for each hospital and as a national
     aggregated rate.


Findings 1.3 The shortfalls in the validity of current national surveillance system to be
discussed at the surveillance workshop are as follows:


(a) Presently, all SSIs associated with “clean” surgical procedures are aggregated and
     expressed as a proportion of all HAI. SSIs are not expresses by type of procedure (i.e.
     not as a proportion of a specific procedure). This method of data collection and
     analysis for SSI can not provide information about the procedure which has the
     greatest rate of infection for targeted IC efforts.




Malaysian National Nosocomial Infections Surveillance System                                              5
     The total number of the surgical patients audited during the point prevalence survey is
     not documented and therefore, the total number of patients undergoing each surgical
     procedure is not used as the denominator.


(b) Not all UTIs are the result of the quality and safety of clinical care. Therefore, this
     indicator can not provide IC information with which to focus IC activities. Surveillance
     options include either substituting UTI with “catheter-related UTIs” or removing UTI
     from the surveillance system.


(c) The usefulness of “Other” infections is limited and can not indicate quality and safety of
     clinical care. These HAI are included in the estimate of the magnitude of all HAI yet do
     not provide information with which to target infection control activities.


(d) Definitions used for some HAI are not presently in accordance with international
     criteria.


(e) An examination of the current rates identified that the numerator for MRSA infection
     includes all positive swabs plus blood cultures and analysed as a proportion of
     admissions. Positive swab cultures do not always provide a valid method of identifying
     MRSA infections as many positive swabs may reflect colonisation rather than
     infection.




The concept of process control chart statistics for analysis of MROs was presented to the
MOH who requested a return second visit for a workshop to key IC staff to learn about this
method.




Malaysian National Nosocomial Infections Surveillance System                                6
Objective 1. To advise on the development of a Malaysian Nosocomial
Infection Surveillance System (to include MRSA, ESBL & Klebsiella
surveillance).


Activities 2.1
2.1 Advise on a national surveillance system began with a debriefing by the MOH (see
Objective 3, page 2) and by engaging in discussion with the clinical staff who attended
lectures on surveillance at the Melaka Hospital, 14th April 2007, and Putrajaya Hospital,
15th April 2007.


Hospital lectures included:
       o surveillance methodologies
       o the resource and time requirements for periodic and continuous surveillance
          methodologies and the associated weaknesses and strengths of data collected
          with both approaches
       o an overview of several suggestions for streamlining the current system (Annex 4);
       o strategies for hand hygiene compliance
       o MRSA control (Annex 5)


Lectures were followed by a tour of each hospital and discussions with the hospital
infection control staff and hospital chief executive about their infection control issues and
their experience with the current surveillance system.


Findings 2.1 Tours of two hospitals and discussions with hospital staff provided important
insights into the diversity of the IC programmes and activities of the IC staff at the
provincial and urban hospitals.


        2.1.1 Like most healthcare systems, the expertise of IC programmes ranges from
        novice to expert, where hospitals may or may not have a microbiologist or
        infectious diseases physician heading the IC team. The hospital IC programme
        headed by a novice IC doctor had attempted to provide an excellent IC
        programme. However, the novice staff acknowledged that they were, from time to
        time, in need of expert advice from MOH or a panel of experts on whom they could
        call.




Malaysian National Nosocomial Infections Surveillance System                               7
        2.1.2 The IC staff held the following views on the current system:
            o    twice yearly data collection was useful however:
                     o   data collection was resource intensive
                     o   required the collection of too many healthcare associated indictors
                         which did not provide information to focus IC activities
            o    continuous surveillance of MRO was beneficial but the annual rates were
                 not a timely estimate of actual endemic levels of MROs.


        The WHO consultant concurred with the above findings.


        2.1.3 Availability of resources for hand hygiene, including basins for water washing
        and alcohol hand rub, in both hospital visits was less than 100%. Alcoholic hand
        rub was available on the trolleys in each ward however, clinical staff do not always
        take the trolley to the patients‟ beds and alcohol rub was not available at the end of
        every bed (as recommended by WHO Cleaner Care is Safer Care Guidelines).


        2.1.4 Cohorting (quarantining) of MRSA infected patients ranged from a single
        bedded ward to cohorting MRSA infected patients at the end of an open16-bedded
        ward. As is the case in most hospitals world-wide, nursing staff provide shared
        care between MRSA infected and non infected patients, and the hand hygiene
        compliance is very low with high transmission of MRSA. Cohort-nursing (where
        nurses are dedicated to only caring for MRSA infected patients) has been proven
        to reduce the risk of cross transmission even when hand hygiene compliance is as
        <40%. The observation made of hand hygiene compliance in general during the
        field trip of two hospitals was poor, cohort-nursing was not practiced and where
        MRSA infected patients were nursed at the end of a ward, nurses did not use
        personal protective equipment (PPE) or practice hand hygiene between nursing
        care of MRSA infected and non infected patients.


        2.1.5 Screening for MRSA is not currently performed for at-risk admissions
        (all admissions to the orthopaedic wards and ICU).


        2.1.6    Previously      identified    MRSA      infected/colonised   patients   are   not
        recognised on readmission because they do not have their medical records
        coded as being an “MSRA alter” patient.




Malaysian National Nosocomial Infections Surveillance System                                    8
To achieve Objective 1 a workshop (Objective 4) was run to consult with key stakeholders
in IC to gain consensus for the new programme that would meet the needs of all levels of
healthcare facilities.


Objective 4. To provide training in (Hospital Epidemiology) National
Surveillance and NNISS to Ministry of Health staff.



Activity 3.1 Workshop on National Surveillance Methodology:
Two separate workshops, located in Langkawi, were given to nurses and
microbiologist/infectious diseases physicians, each 1.5 days in duration.       Five
mission objectives (that included a Surveillance Workshop but not Hospital
Epidemiology Workshop) were achieved over a four-day meeting schedule (Annex
2). The content of the workshop lectures included an overview of international
surveillance systems, with advantages and disadvantages of the various
methodologies (Annex 4). Participants were presented with their current surveillance
approach and the national results for the period 2003 to 2006 (presented by the
MOH). Small focus group discussions were then held with the participants about the
usefulness of the national results, their experiences with the present surveillance
system and their requirements of a new system (Annex 6) followed by an open
discussion group (Annex 7) when the consultant explored the general consensus
about:

        the usefulness of each clinical indicator presently collected,

        the advantages and disadvantages of an alternative continuous incidence
         surveillance system, including the significant resources required for
         continuous surveillance,

        the economics of twice yearly prevalence surveys,

        the importance of continuous surveillance of MROs,

        possible modifications to the present prevalence surveillance that would
         streamline the data collection and alter the analytical methodology,

        a proposal for enhancements to the current infection control programme that
         would include the use of process control chart statistics to provide monthly
         feedback of MRO infections to clinicians. A streamlined system for the




Malaysian National Nosocomial Infections Surveillance System                            9
        prevalence surveys would reduce the time for data collection and improved
        reliability and timeliness of MRO data.



Findings 3.1

The key stakeholders reached consensus about the new surveillance system for
Malaysia and this was presented to the MOH delegate responsible for surveillance.

Changes to the components of surveillance: The nurses and doctors at the surveillance
workshop presented their groups‟ evaluation of the present surveillance system and their
suggestions for change. Each group‟s evaluations were aggregated and presented to the
wider group by the consultant with advantages and disadvantages of each suggestion.
Several modifications that had been previously identified from the field trips and were
discussed with the MOH prior to the workshop were given approval by close to 100% of
the participants. Agreed was reached on the removal of proposed components in the
current surveillance system that were thought not to positively contribute to the hospitals‟
IC activities (Annexes 7 and 8). Of those components that remained in dispute further
discussion reached 100% consensus for the removal of these from the surveillance
program (Annex 9).


       It was then agreed that with the present resources available to hospital IC
        departments, periodic (twice yearly) prevalence survey should continue for those
        clinical indicators agreed to be kept.


       The group agreed that several risk factors not currently collected during the
        surveys should be included that would improve the calculation of rates of those
        indicators to be retained so that the rates would assist in better targeting IC
        activities.


       Clinical indicators that were resource intensive and did not provide a valid insight
        into IC problems would be removed from the prevalence surveys (e.g. Clinical
        Sepsis, Urinary Tract Infection, Ventilator Associated Pneumonia and “Others”).


       It was agreed that MRO continuous surveillance was valuable and should be
        continued in the new national surveillance programme.




Malaysian National Nosocomial Infections Surveillance System                              10
       It was agreed that MRO data would be analysed using monthly PCC statistics as
        well as reporting annual rates.



The new surveillance program accepted by the participants consists of:

    1. Improving the current surveillance components of the prevalence surveys to
    streamline data collection, mostly utilising passive surveillance (pathology)
    methodology.

     Prevalence survey twice yearly of SSI: all clean surgical procedures to be
     replaced with targeted surgical procedures (that would represent all degrees
     of contamination not just clean procedures).

           o     the current reporting of percentage of types of surgical site infection
                as a proportion of the total HAI is to be replaced with rates for
                targeted surgical procedure expressed as a rate of each targeted
                surgical procedures (requiring the collection of both the denominator
                and numerator for each targeted procedure).

     Prevalence surveys twice yearly of bloodstream infections: bloodstream
     infections as a proportion of all hospital acquired infections to be replaced with
     central venous line-related bloodstream infections per patient-days in ICU
     (in those patients with at least one CVL in situ).

     Continuous surveillance of MROs: positive swab and blood cultures are included
     in the rate. It is more helpful to identify whether MRO‟s are causing serious or
     life-threatening disease and would require MROs to be reported from sterile
     sites (blood cultures) only at this stage and not to include isolates from non
     sterile sites (swabs).



            o    Continuous surveillance of methicillin resistant Staphylococcus aureus
                 (MRSA):      isolates from positive blood and swab cultures to be
                 replaced with MRSA identified from blood cultures only and expressed
                 as MRSA blood culture infections per 10,000 occupied bed days.

            o    Continuous surveillance of extended spectrum beta lactamase
                 (ESBL): isolates from all positive cultures to be replaced with ESBL
                 identified from blood cultures only and expressed ESBL blood
                 culture infections per 10,000 occupied bed days.


Malaysian National Nosocomial Infections Surveillance System                               11
            o    Adopt process control chart statistics for monthly analysis and
                 presentation of MSRA, ESBL and Klebsiella data.



2. Cease surveillance of ventilator associated pneumonia (VAP) infections, clinical
sepsis, urinary tract infections (UTI) and all those remaining healthcare associated
infections that come under the category of “Other”.



3. Include the collection of process indicators during the twice yearly prevalence
surveys that can provide a flag to staff of the adherence to important infection control
policies. These could include:

                The correct duration of peripheral venous lines (≤ 72 hours).

                The unnecessary exposure to CVL by measuring the percentage of
                 CVL removed from patients being discharged from ICU to wards.

                The correct prophylaxis coverage in surgical patients undergoing
                 targeted surgical procedures, by measuring the percentage of surgical
                 patients receiving correct time, dose and type of antibiotic prophylaxis.

                A reduction in unnecessary antibiotic prescribing behaviour that is
                 associated with MROs by targeting specific antibiotic usage (e.g. 3rd
                 and 4th generation cephalosporins, and vancomycin use).

                Compliance with the WHO Guidelines for hand hygiene.




Malaysian National Nosocomial Infections Surveillance System                                 12
Objective 5. To advise on surveillance strategies for the control of
Methicillin Resistant Staphylococcus aureus (MRSA)
                                                  and
Objective 2. To advise on methods for enhancing the hand hygiene
programme


Activity 4.1


MRSA control and prevention discussions with hospitals staff and MOH included:
                    current nursing and infection control strategies
                    the use of screening of high risk patient groups
                    analytical techniques that could provide timely information about control
                     strategies
                    hand hygiene


I was provided with the rates of MRSA in each hospital in Malaysia. I was also given
insight into infection control practices and barriers to compliance with standard precautions
and hand hygiene guidelines in Malaysia through discussions with participants at the
surveillance workshops, observations during the hospital tours, a verbal report of hand
hygiene audit from the Malaysian HCWs and from discussions with the MOH.


Findings 4.1


MRSA is contributed to by inappropriate antibiotic use, low nurse to patient ratio, shared
nursing care of MRSA positive and negative patients and poor compliance with personal
protective equipment use and hand hygiene.


        Alcohol hand rub is available on nurses‟ trolleys but not available at the end of
         every patient bed or as individual containers for healthcare workers to carry
         around in their uniform. This reduced availability of hand rub is a barrier to
         compliance. On observation, hand hygiene was similar to international findings
         that report clinical staff practice hand hygiene inconsistently and is not practiced
         when they believe they are not personally at-risk of infection. For example, hand
         hygiene by nurses caring for MRSA positive and negative patients in an open 16-
         bedded ward observed during one of two field trips was not practiced before or



Malaysian National Nosocomial Infections Surveillance System                               13
         after obvious hand hygiene opportunities and neither was personal protective
         equipment.

        Lack of isolation rooms for patients with a MRO infection and low levels of hand
         hygiene will contribute to high rates of HAI in Malaysia.

        Wards have IC link nurses but the medical staff are not well informed about IC and
         do not strictly comply with hand hygiene protocols.

        The delay in analysis of MRO endemicity occurs because of the need to collect
         sufficient data with which to calculate a reliable rate which in turn delays a review
         of current IC strategies. A brief overview of Process Control Chart (PCC) statistical
         analysis for MROs was discussed including the concepts of random chance,
         systems errors, special event errors, mean, standard deviation, 95% Confidence
         Intervals (95%CI) around the mean, exponentially weighted moving average
         (EWMA), 95%CI around the EWMA, excel spread sheet functions, EWMA chart
         production and the interpretation of the charts.




Malaysian National Nosocomial Infections Surveillance System                               14
Objective 4. To provide workshop in Hospital Epidemiology (National
Surveillance and NNIS) to MOH staff


Activity 5.1 Workshop in Hospital Epidemiology


The duration of the surveillance workshops in Langkawi were not long enough to introduce
participants to Hospital Epidemiology therefore, a subsequent workshop was requested by
the MOH that would include Process Control Charts (PPC) that was held in August. The
content of the Hospital Epidemiology course included the theory of causation that includes
study design (randomised control trials, cohort, case-control, cross sectional and
surveillance), the weaknesses and strengths associated with each, confounding and
measurement (errors in study design and data collection) and introduction to risk analysis
(relative risk, odds ratio, p-values, 95%CI), then bringing together all the preceding
concepts, participants learn to critically appraise medical and nursing literature for
evidence informed decision making.


Findings 5.1
        Due to (1) the inability to secure a flight for the consultant to arrive in Sabah on
         Monday morning, (2) the clinicians‟ time constraints and (3) to compliment the
         inclusion of PPC statistics for the control and prevention of MRSA and ESBL, the
         August workshop focused on PPC (Annex 15) with only a brief overview of
         Hospital Epidemiology (Annex 13). The majority of participants mastered the use
         of the Excel spreadsheet with the Exponentially Weighted Moving Average
         calculations    pre-programmed         with   calculations   for   the   chart   production.
         Participants practiced with data from the Sabah Hospital and their own data.
         Discussion about the interpretation of the charts identified that the majority of
         participants understood the analysis. Participants successfully gained basic excel
         spreadsheet skills, an ability to manually calculate means, Shewhart chart 95%CI,
         EWMA and Upper EWMA (2 standard deviations around EWMA), plus interpret
         the difference between random fluctuation (no real change in infection rate) from
         “special event signals” (i.e. increase in rate due to an outbreak or individual error)
         in a PCC and “systems signals” (changes in the endemic rate without an
         outbreak).




Malaysian National Nosocomial Infections Surveillance System                                      15
                            Conclusions and Recommendations

Objective 3. To engage in discussions with the Ministry of Health staff on the
contents of the workshop for national surveillance.


Conclusion 1.1

Given the time allocated and learning objectives, offering course in Hospital Epidemiology
at a surveillance workshop would be unwise.

Recommendation 1.1

To present to IC staff very briefly only an introduction to Hospital Epidemiology, that apply
only to surveillance. The components chosen were to assist the participants gain an
appreciation of the importance of reliability and validity of data and the limitations of rates
produced from small sample sizes using the current statistical analysis.

Conclusion 1.2

The current surveillance system requires that all HAI are surveyed twice yearly with
continuous surveillance of MRSA and ESBL. The use of prevalence surveys is an
excellent use of resources, freeing up IC staff to use their skills on IC prevention activities.
However, hospital-wide survey is too broad and time-consuming, attempting to capture
every HAI, resulting in information that lacks focus with which to target IC prevention and
control activities.



Recommendation 1.2

Before making recommendations about modifications to the current system, focus group
discussions were run with the key IC staff who attended the surveillance workshops. They
were asked, given the IC resources, their at-risk patient groups and their facility‟s most
common infection problem, to consider several modifications that would streamline survey
activities yet provide information to assist them in controlling transmission.




Malaysian National Nosocomial Infections Surveillance System                                  16
Conclusion 1.3

Initial impressions of the limitations of the current methodology, data collected and
analysis to be discussed at the surveillance workshops are:

        The incorrect denominator can not provide rates that will indicate the focus of the
         IC prevention strategies. For example, SSI uses total HAI as the denominator.
        The breadth of data collection during the twice annual surveys is possibly too time-
         consuming.
        “Non-catheter associated UTI” indicator does not provide an indicator that reflects
         the quality of patient care as many non-catheter related UTIs may or may not be
         associated with medical/surgical interventions.
        The data collection for the “Other HAI” and “non-catheter related UTIs” indicators is
         time consuming and provides very limited information for IC interventions.
        Combining positive isolates from both sterile (blood culture) and non sterile sites
         (e.g. swab culture) for the estimation of MRSA and ESBL infection. Isolates from
         non sterile site may be colonisation rather than infection. Unless a consistent at-
         risk patient group for colonisation is tested during each survey then random
         variation in the frequency of colonisation isolates will make this the estimate of
         MRO infection unreliable.
        Data are not always collected using internationally accepted criteria for HAI.


Recommendations 1.3

Findings of the limitations of the current system and suggested modifications that are to be
presented to key stakeholders at the hospital lectures and surveillance workshops for
discussion include:

    i.   SSI rates presented as a proportion of all clean surgery is incorrect. Several
    surgical procedures must be chosen to be surveyed and expressed as a proportion of
    the total for that procedure. For example:


    SSI associated with colorectal surgery during period X                   * 100
    Total number of colorectal procedures performed during period X


     This calculation should be used to estimate the magnitude (proportion) of infection
     occurring in each targeted procedure and those with higher than accepted rates could
     then be targeted for IC intervention.

Malaysian National Nosocomial Infections Surveillance System                               17
ii.    UTI should be dropped from the new surveillance system and catheter-related UTI be
       reviewed at a later date.


iii.   Aggregated “Other” HAI should be dropped from surveillance.


iv.    The definitions of HAI must be valid and reliably applied. The use of internationally
          accepted criteria will ensure clinicians that the rates have high validity and, with
          training, high reliability. The Centres for Diseases Control (USA) definitions are
          recognised internationally as valid criteria for the classification of HAI for the
       purpose of surveillance and freely available on the internet.


v.     The use of swab cultures may over estimate the endemic levels of MRSA and ESBL
       because positive swab cultures may simply reflect colonisation rather than infection.
       Therefore, rates should be calculated for isolates from sterile (blood cultures).
                Rates should be expressed as per 10,000 occupied bed days rather than
                 per 10,000 admissions.
                When stratifying rates by speciality units (e.g. orthopaedics and ICU),
                 infections that occur or are detected (date of isolates sent to the laboratory)
                 more than 48 hours after admission to the unit or within 48hrs of discharge
                 from the unit are deemed to be associated with that unit.




Malaysian National Nosocomial Infections Surveillance System                                 18
Objective 1. To advise on the development of a Malaysian Nosocomial
Infection Surveillance System (to include MRSA, ESBL & Klebsiella
surveillance).



Conclusion 2.1

2.1.1 IC programmes are headed by clinicians with expertise in IC that ranges from novice
to expert. Many hospitals have no medical microbiologist or infectious diseases physician
heading the team.



2.1.2 There was a consensus by the IC staff that the current surveillance system required
the collection of unnecessary data and that the omission of important denominator data
prevented the hospital from developing rates that would be useful in planning intervention
strategies. Staff also believed that delayed national reports from the MOH meant
thresholds were retrospective rather than current rates.


2.1.3 Accessibility of alcohol handrub needs to be increased.


2.1.4 Shared nursing between MRSA patients and non-infected MRSA patients occurs in
Malaysia with hand hygiene compliance often less than 40% plus standard precautions
(gowns and gloves) was not observed to be used by nursing staff between
colonised/infected MRSA and non colonised/infected patients.


2.1.5 Target admissions to wards with high-risk patients (e.g. orthopaedic and ICU) for
MRSA screening to assist in the identification MRSA infected/colonised patients for the
strict IC management (e.g. personal protective equipment, cohorting patients with cohort
nursing, and coding of patient‟s medical records as „previously MRSA infected/colonised
for testing on future readmissions).


2.1.6 Previously identified MRSA infection/colonisation patients should have their medical
records coded so that on readmission these patients can be screened again for MRSA
and appropriate IC precautions used.




Malaysian National Nosocomial Infections Surveillance System                             19
Recommendation 2.1

2.1.1 The number of educated Infection Control Nurses and IC doctors should be
increased.

The MOH should provide a standardised introductory IC programmes to nurses and
doctors to ensure that any clinician involved in IC gain a standard level of IC knowledge
and skills.

IC staff would benefit from a national panel of expert IC advisors who provide assistance
to novice hospital IC staff.

2.1.2 Reduce the number of HAI clinical indicators and replace these with enhanced
indicators to improve the quality and timeliness of rates. Process indictors (of the hospital‟s
choice) can provide information for local IC staff about the adherence of IC policies and
protocols that is often more useful than clinical indicators measuring outcome (infection).


2.1.3 For large urban hospitals, provide alcohol hand rub at the entrance of patients‟ room
and at the end of patient‟s bed.


For provincial hospitals where there may be open wards, provide alcohol hand rub at the
end of patient‟s bed.


Provide small personal containers of alcohol hand rub for all clinical staff.


2.1.4 The MOH should introduce an IC directive to hospitals about the need for strict hand
hygiene in areas where nursing is shared between MRSA and non-MRSA patients and
follow this up with a focused education programme.


The MOH to introduce an IC policy and education programme for strict adherence gown
and glove use by nursing and medical staff and visitors for all MRSA infected patients.


For those hospitals where single rooms are not available to cohort MRSA patients, and
where wards care for MRSA infected and non infected patients together, the MOH should
consider introducing the practice of dedicated cohort-nursing (nurses caring for MRSA
infected patients do not nurse non-infected patients) in hospitals where the MRSA
endemicity is high. Where dedicated cohort-nursing can not be practiced then hospitals



Malaysian National Nosocomial Infections Surveillance System                                20
must prove that they comply with strict gowning, gloving and have very high (>75%) hand
hygiene compliance between nursing patients.


2.1.5 Where facilities have high endemicity of MRSA, the MOH should introduce a policy
for targeted MRSA screening for all admissions to the orthopaedic ward and ICU.


2.1.6 All hospitals should introduce the practice of coding the medical records of patients
with a previous MRSA infection/colonisation. Readmissions of these coded patients would
indicate they should be retesting for MRSA and cohorted if positive, with all staff being
required to use strict gown, glove and hand hygiene practice with these patients.


Conclusions 3.1

1. All rates that the hospitals calculate and the national aggregated rates have limited
usefulness. Twice yearly prevalence survey is an excellent use of resources however, the
breadth of the surveys is too wide and too time consuming. Most of the clinical HAI
indicators should be removed from surveillance which would provide more time to collect
correct denominator data.

2. The current use of continuous surveillance of MRSA and ESBL provides valid and
reliable rates, however the rate should use occupied bed-days as the denominator (not
admissions) and the provision of national rates is not timely.


3. Surveillance of prescribing patterns for targeted antibiotics (e.g. third generation
cephalosporins, and vancomycin) through pharmacy departments should be
introduced in the twice yearly prevalence survey.

4. Hand hygiene compliance rates should be included in the biannual prevalence
survey.

5. A reminder campaign about hand hygiene should be continuous directed at clinical
staff. This campaign should challenge the clinicians‟ community-based beliefs and
practices which are not acceptable in the healthcare setting.

6. Nursing staff find it difficult to correct medical staff IC-related practices.

Nursing staff perceive the medical staff as role models for IC related practices,
including hand hygiene practice. This view is upheld in the international literature.



Malaysian National Nosocomial Infections Surveillance System                              21
Medical staff are currently perceived by nursing staff as not taking IC activities
seriously nor taking an active role in IC.



Recommendation 3.1


1. Deletion of HAI clinical indicators from the prevalence surveys: Twice yearly prevalence
surveys should have a reduced number of HAI collected (Table 4a).
        Drop clinical sepsis, BSI, VAP and “Other” Infections from the surveys.
        Only survey bloodstream infections associated with CVL and only in ICU in large
         hospitals. The survey period should be 4 weeks and be a consistent surveillance
         period over the years.


2. Alterations to continuous surveillance (Table 4b):


i.       ESBL, MRSA, and Klebsiella
         For MRSA rates to reflect infection, the current practice of including isolates from
         positive swab culture should cease as isolates from swabs do not distinguish
         between colonisation and infection. If MRO isolates from swab cultures were to be
         included the swabs must derive from a consistent patient group (orthopaedic or
         ICU) and should be swabbed for colonisation on a routine basis. Otherwise, clinical
         swab cultures (that is swabs taken for suspected clinical infection) provide
         inaccurate estimate of infection as many isolates will only be colonisation and the
         pathology reports may not make a clear distinction between infection and
         colonisation. MRO rates should be calculated for positive blood cultures.


        Process control chart analysis should be introduced for rapid monthly analysis of
         MROs at the local hospital level. Separate process control charts should be
         produced for each MRO to visually illustrate the endemic levels against a
         predetermined upper limit of counts for that MRO. When the MRO charts show the
         rates of infection cross the predetermined acceptable limit, this will indicate that
         urgent IC strategies are required. Predetermined limits for each MRO can be
         lowered if the IC staff believe the rates have become stable or are remaining below
         the predetermined limit.


        The rate of MROs should be reported per 10,000 occupied bed-days not per
         10,000 admissions and reported to only 1 decimal point.

Malaysian National Nosocomial Infections Surveillance System                               22
3. Improvements to the prevalence methodology surveys (Table 4b):

     i.   Identify internationally accepted criteria for HAI (e.g. CDC definitions). Train all IC
          staff in the identification of HAI in accordance with the criteria (to ensure reliability
          of data collection).

     ii. All rates should be reported to 1 decimal point.



4. Additions to the prevalence surveys (Table 4b):
A new targeted approach will allow staff more time to collect informative data. Data
collection should include:
i.   SSI
          Target specific surgery HAI with hospital to choose the procedure(s). The choice
          should include those surgical procedures that are commonly performed in the
          healthcare facility.

          SSI to be calculated as proportion of the specific procedure (not as a proportion of
          the total clean procedures).

          The appropriate denominators would require the total number of a specific surgical
          procedure to be collected during the survey that was performed for a specific
          period (e.g. the denominator for SSI associated with colorectal procedures
          performed during period X would be all colorectal procedures performed during
          period X).

          The survey period should be long enough to be able to calculate a reliable rate of
          SSI. The period should not be short as only superficial infections will have time to
          manifest and to be identified during a short survey period. The majority of SSI
          manifest within 3-4 weeks post surgery. Whatever the period for SSI surveillance is
          chosen, both the numerator and the denominator data must reflect this period (ie
          SSI for a specific surgical procedure that manifest over a 4 week period is collected
          as well as the collection of the total number of specific surgical procedures
          performed during the same 4 weeks).

ii. Antibiotic prescribing patterns

          Specific antibiotic prescribing patterns related to MROs should be targeted in the
           twice yearly surveys by the pharmacy department. This information will assist IC
           committees to evaluate the introduction of controlled antibiotic prescribing for

Malaysian National Nosocomial Infections Surveillance System                                    23
        certain antibiotics. The survey period can be as short as one week or as long as 4
        weeks – but should be a consistent surveillance period over the years.

       The twice yearly prevalence survey results of “defined daily dose “ (DDD) for e.g.
        3rd generation cephalosporins, collected by the pharmacy departments should be
        feedback to the IC Committee and prescribing clinician.

       The DDDs should be presented with the rates of MROs plotted on process control
        charts with an aim to (i) reduce resistance and (ii) educate prescribing patterns.

iii. Hand hygiene

       Perform twice yearly prevalence audits of hand hygiene compliance as an IC
        process indicator. This survey should not aim to act as providing rates with which
        to punish staff but rather, act as an education tool through the activities prior to the
        survey. The survey period be as short as 1 week but should be consistent over the
        years.

       To prepare clinical staff for the survey each clinician should identify a “hand
        hygiene buddy” who will remind them to comply whenever they are seen to forget.
        This should be done two week prior to the hand hygiene audits bi annual
        prevalence survey which will act as a reminder/education service.

       Hand hygiene compliance rates should be presented with MRO rates plotted on
        process control charts for the preceding 6 months and provided to the hospital IC
        Committee and feedback to clinicians.



iv. Medical staff as IC role models

       To engage medical staff in IC role modeling, appoint medial staff as “IC link
        Doctors”. The appointment will (i) enable the IC link doctors to correct medical
        staffs‟ poor IC related practices, and (ii) act as a role model for nursing staff who
        look to the medical staff for IC related behaviour.




Malaysian National Nosocomial Infections Surveillance System                                 24
Tables 4a and 4b outline the components and changes to the current surveillance system:
Table 4a Deletions from the current surveillance system
Deletions of current           Recommendation for Modification to             Rationale
component of Surveillance      Current Surveillance
UTI                            Cease surveillance                             UTIs may or may not manifest as a result of
                                                                              poor clinical management. Presently does not
                                                                              provide information to target IC activity.
VAP                            Cease surveillance. The collection of the      Staff happy to continue this indicator even
                               denominator is too time-consuming and the      though the collection of ventilator-days was
                               present definition of VAP is unreliable.       time consuming. A valid and reliable definition
                               Some hospitals wish to continue with same      of VAP infection that is not too invasive
                               methodology.                                   technique for the diagnosis of VAP has not
                                                                              been identified and agreed on.
BSI and Clinical Sepsis        Cease surveillance                             Does not provide information to target IC
                                                                              activities.
All “Other” HAI                Cease surveillance.                            Does not provide information to target IC
                                                                              activities.
SSI                            Alter methodology. Continue with               Currently rates given as percentage of all HAI.
                               prevalence survey twice annually. Data         However, this is not informative of clinical
                               collection to include type of procedure and    management of each type of procedure.
                               number infected/not infected during 4 week     Infected plus not infected by procedure will
                               survey period.                                 provide the correct denominator to calculate
                               Rates per 100 same type of procedure.          percent SSI by each procedure performed and
                               Do not separate rates by Deep and Organ        surveyed.
                               space, but present rates of SSI by severity    Exclusion of the stratification of SSI by Deep
                               of infection to be separated for only “Skin”   and Organ Space required observation at time
                               and “Deeper” infections.                       of re-incision or x-ray. Therefore, SSI by Skin
                               Report rate to 1 decimal point.                or Deeper (aggregation of Deep and Organ
                                                                              Space) provides evidence of superficial and
                                                                              more serious infections when x-ray of re-
                                                                              incision is not performed.




Malaysian National Nosocomial Infections Surveillance System                                                       25
Table 4B. Modifications and additions to the current surveillance program
Modifications to current           Recommended methodology                            Rationale
component of surveillance
Surveillance of the MRSA and       Continue to collect data for sterile isolates      This excludes colonisation from the infection
ESBL                               (blood cultures) to be provided by 10,000          rate. Each occupied bed-day each patient
                                   occupied bed days. Report rate to 1 decimal        experiences is a better indicator of risk period
                                   point.                                             than the single “admission” the patient
                                                                                      provides in a rate expressed per 10,000
                                                                                      admissions.
International definitions of HAI                                                      To report valid rates.
New Component of Surveillance      Recommended methodology                            Rationale
Central Line Associated            Prevalence survey twice annually for 4 weeks.      CLAB is a potentially life threatening infection
bloodstream Infection (CLAB)       All positive BSI associated with central venous    not included in the survey except indirectly
                                   catheters in ICU patients to be reported as        through an aggregated BSI rate. Focusing on
                                   1000 central line-days. Report rate to 1           central line days allows for CVL associated
                                   decimal point.                                     clinical practices to be targeted when CLAB
                                                                                      rates rise. E.g. insertion techniques (patient
                                                                                      position, skin preparation, preferred insertions
                                                                                      site (subclavian)) and clinician technique
                                                                                      (100% assistance, junior staff credentialed for
                                                                                      all insertion sites, only 2 passes before
                                                                                      handing over to senior clinician, hand hygiene,
                                                                                      gowns, hat, mask, gloves). A 4-week
                                                                                      surveillance period is required to collect a
                                                                                      reliable number of cases of infection.
Targeted Antibiotic prescribing    Prevalence survey twice annually for between       Pharmacy to report the prevalence twice
                                   1 and 4 week surveillance period, depending        annually for targeted antibiotics and report
                                   on the size of hospital. Rates reported as         rates back to clinicians with target DDD to
                                   Define Daily Dose.                                 decrease prescribing of antibiotics related to
                                                                                      MRO.
Hand Hygiene                       Prevalence survey twice annually for a 1-week      Two weeks prior to audit, have staff pair up
                                   survey period. Rates as percentage of              with a hand hygiene buddy who will help
                                   observed compliance for hand hygiene               remind each other about good hand hygiene
                                   opportunities, reported separately for each type   practices. Overt hand hygiene prevalence
                                   of hand hygiene practice (in accordance with       audit. Aim to improve in the long term hand
                                   WHO Guideline audit). Introduce hand hygiene       hygiene by healthcare workers, patients and
                                   programmes into primary schools.                   their visitors by improving awareness and
                                                                                      practice in the community.




     Malaysian National Nosocomial Infections Surveillance System                                                          26
Objective 5. To advise on surveillance strategies for the control of Methicillin
Resistant Staphylococcus aureus (MRSA)
and
Objective 2. To advise on methods for enhancing the hand hygiene
programme



Conclusion 4.1

The strategy to reduce the spread of MROs must be multi-focused aimed at improving:

       hand hygiene compliance
       antibiotic prescribing practices
       adherence to the use of personal protective equipment (gowns and gloves) when
        nursing patients with MRO
       IC practices for non infected patients when nursing is shared between MRSA and
        ESBL infected and non infected patients
       identification of MRSA infected/colonised patients
       IC practices by medical staff




Recommendation 4.1

       Three hand hygiene resources must be easily accessible:

            o    sinks with soap
            o    alcohol hand based rub at the end of every patient‟s bed
            o    personal containers of alcohol based handrub for all clinical nursing and
                 medical staff.

       All hospitals should introduce an antibiotic stewardship programme. This
        programme would restrict the prescribing of certain antibiotic (those antibiotics
        related to resistance such as 3rd and 4th generation cephalosporins) to only
        infectious diseases consultant and infectious diseases registrars. All other
        prescribing staff should be required to obtain a code from the infectious diseases
        consultant/ registrar, which is to be written on the prescription. The pharmacy
        department should not dispense more than a 24-hours quantity of the restricted
        antibiotic without the required code.


Malaysian National Nosocomial Infections Surveillance System                                 27
       Strict gown and glove use to be introduced for the shared nursing of patients
        infected with an MRO and non-infected patients.

       Allocation of an isolation room is required in orthopaedic wards for MRSA infected
        patients. The current cohorting positive patients at the end of an open orthopaedic
        ward of non-infected patients who share nursing care should cease.

       For MRO infected patients in all other departments which do not have an isolation
        room, it is preferable to have 100% nurse-cohorting (i.e. dedicated nurse to the
        MRO infected patient who does not share nursing care with non infected patients).
        Nursing must be include (i) strict 100% hand hygiene using alcohol handrub
        between MRSA patients cohorted at end of room prior to leaving MRSA patient
        area and (ii) strict gowns and glove use.

       A MRO alter code on a patient‟s medical record who has been identified as having
        a MRO infection should be introduced to improve IC practices during readmission
        into a shared ward.

       All previously MRO infected patients should be retested. Until the test results
        return, the patient should be considered to be colonised or infected and nursed
        using standard precautions.

       Targeted screening is cost-effective and should be introduced for

            o    all admission into the orthopaedic wards and ICU

            o    all readmissions previously identified as being infected/colonised with a
                 MRO.

       IC staff should focus IC related programmes specifically targeting medical staff in
        the following areas:

            o    hand hygiene

            o    antibiotic prescribing

            o    gown and glove use for the care of MRO infected patients

       An IC link doctor to all wards should be appointed to improve medical staff and
        nurses‟ IC behaviour. The link doctor should be the point of contact for the IC staff
        for the introduction of new IC strategies and the link doctor should be given the
        responsibility to assist other medical staff with IC related knowledge/advise.




Malaysian National Nosocomial Infections Surveillance System                                 28
       Analysis of MRSA and ESBL data collected during continuous surveillance should
        include Process Control Charts (PPC). The hospitals should identify previous rates
        as their initial (upper limit) threshold.

       Hand hygiene compliance audit should be included in the twice yearly survey
        and surveyed for 1 week.

       Two weeks prior to the hand hygiene survey, the “hand hygiene buddy”
        system should be introduced into all wards. This system should involve all
        clinical staff who will choose a peer „buddy‟ to remind them to hand hygiene
        over two weeks preceding the overt hand hygiene audit. The aim of the
        buddy system is to engage all clinicians in the hand hygiene program by
        improving the understanding of healthcare workers that hand hygiene is
        important and to establish a new behaviour that healthcare workers can ask
        each other to comply. The overt audit should act as both an educational
        opportunity and an opportunity to change social norms by helping healthcare
        workers‟ to accept being expected to hand hygiene.

       A hand hygiene campaign should be introduced into primary schools. This
        is a long term strategy and should aim at improving the spread of common
        infections in the community and to alter behavioural and normative
        perceptions about the reason for hand hygiene (from a perception that it is to
        be practiced simply to protect oneself towards a perception that it also
        practiced to protect others from our infections).




Malaysian National Nosocomial Infections Surveillance System                             29
Objective 4. To provide workshop in Hospital Epidemiology

Conclusion 5.1

       This analysis was new to all of the participants.
       The majority of participants understood the calculation for PPC, how to enter data
        onto the Excel spreadsheet and how to produce charts.
       There were participants who require further assistance in entering data onto the
        spreadsheet, producing a chart and interpreting the chart.


Recommendation 5.1

       Provincial IC groups should be formed who should assist each other in the use of
        PCC.

       Hospitals should use the national rates of MROs for size of hospitals as their initial
        upper limit threshold for infection count when developing the process control.
        Alternatively, if the hospital‟s own count is lower, then the hospital‟s IC Committee
        should assist the IC staff to set the upper limit thresholds for MRSA and ESBL.

       After six months of plotting data, the threshold should be reviewed and the
        threshold count may be lowered when the charts shows the level of MRO infection
        is consistently at or lower than the threshold. Lowering a threshold should only be
        done when the IC strategies for the control of MROs have been in place for at least
        6 months.

       At the hospital level process control charts should be provided to the ward staff so
        they can visual the changes in MRO endemicity.

       The MOH could provide the IC staff with a follow-up workshop to review the use of
        process control charts and threshold settings.




Malaysian National Nosocomial Infections Surveillance System                                30
Acknowledgements

Dr Mohd. Shah bin Dato Idris assistances with the workshops, arrangements for the
hospital visits, Kuala Lumpur s and Melaka hospitals, and availability for the many detailed
discussions with him, were of enormous help in my appreciation of their requirements of a
national surveillance system. I would also like to thank his staff, Sisters Rokiah Judin,
Halijah Hashim and Emira Biti Ghazali, for their organisational assistance during the
workshops.




Malaysian National Nosocomial Infections Surveillance System                                31
Annex 1. WHO Original Terms of Reference
1. To develop the MOH Hospital Infection Control Programme‟s National Infection
Surveillance System (NISS) by:
            a) providing recommendations to enhance the effectiveness of current National
            Nosocomial Infection Surveillance System (NNIS) in MOH hospitals;


            b) improving the NNISS e.g. a national database of performance in Nosocomial
            Infection Control Indicators based on international standards; and


            c) developing a sound monitoring and feedback programme that will provide
            useful data for medical practitioners and health care managers to make
            accurate policy and clinical decisions from the indicator data.


2. To conduct a national workshop and training on healthcare acquired infections and
    NNISS.


3. To submit report.




Malaysian National Nosocomial Infections Surveillance System                          32
Annex 2. Modified Terms of Reference and Time Frame by MOH
1.      To advise on the development of a Malaysian Nosocomial                  Infection
        Surveillance System (include MRSA, ESBL & Klebsiella surveillance)

2.      To advise to enhance the hand hygiene programme

3.      To engage in discussion with MOH staff on workshop contents

4.      To provide training on Hospital Epidemiology to MOH staff

5.      To advise on MRSA strategies for control and development of MRSA control
        programme (based on Australian experience)

Day 1. (Tuesday 13th March)
MOH to present on the Malaysian Nosocomial Infection Programme. MOH to present on
the WHO Global Patient safety Challenge (Clean Care is Safe Care).

M-L to engage in discussion with MOH on their future direction of the Malaysian
Nosocomial Infection Surveillance System (including MRSA monitoring & prevention
programme), discussing the NSW and QLD experiences with surveillance - PowerPoint on
accreditation & hospital infection clinical indictors plus discussions (1.5 -2 hours)
M-L to engage in discussion about hand hygiene – the WHO programme, the literature on
hand hygiene and own research experience in hand hygiene behaviour. PowerPoint on
hand hygiene and discussions (3/4-1 hour)

Day 2. (Wednesday14th March)
Visit to Melaka hospital with post-visit discussions
Lectures on NNIS, MRSA and Hospital Epidemiology for MOH staff in Southern region

Day 3. (Thursday 15th March)
Morning Visit to Putrajaya Hospital - short course in NNIS and Hospital Epidemiology
2.30 pm visit Deputy D-G (Dato' Dr. Noorimi) and Director of Medical Development visit to
Melaka hospital to discuss contents of the training programme on Infection Control
Surveillance and Hospital Epidemiology. - For Langkawi workshop

Day 4. (Friday 16th March)
Discussions with MOH staff on workshop details

Day 5. (Saturday 17th March) Free day

Day 6. (Sunday 18th March)
Afternoon - Fly to Langkawi - eticket has been booked. M-L to collect at the MAS ticketing
counter, KLIA

Day 7-10. (Monday 19th to Thursday 22nd March)
Workshop on Infection Control Surveillance and Hospital Epidemiology (same Hospital
Epidemiology course in taught to WHO Fellows in Sydney, December 2006). Starting the
workshop off with Dr Paa giving a presentation on accreditation/indictors.

Day 11. (Friday 23rd March) 10pm Depart KL-Sydney




Malaysian National Nosocomial Infections Surveillance System                           33
 Annex 3. Time Frame for Mission in National Surveillance of Hospital
Infection for Malaysian Ministry of Health


Date and location            Activity                                       Attendees
Tuesday 13th March 2007
9:30am – 4pm                 Discuss the content lectures, workshop and     Dr Mohd. Shah bin Dato Idris
Malaysian    Ministry   of   surveillance program.                          Dr Razaini biti Mohd Zain (Deputy Director Quality of
Health (MOH)                                                                Medical Care Section)
                                                                            Dr HJH Kalsom Biti Maskon
                                                                            M-LM
Wednesday 14th March
2007                         Activity – Two lectures on Surveillance and    MOH:
7am – 7pm                    MRSA control and Hand Hygiene (Appendix        Dr Mohd Shah
Melaka Hospital              1).                                            Dr Paa Nasir
                             Tour of Hospital                               Melaka Hospital
                                                                            Dr Abu Bakar (Director)
                                                                            Dr Kuan Geok Lan (Infection Control)
                                                                            Matron Nyaros
                                                                            M-LM

Thursday 15th March 2007
8am – 4pm                    Two lectures on Surveillance and MRSA          Dr Mohd Shah, Sisters Rokiah Judin, Halijah Hashim
Putrajaya Hospital           control and Hand Hygiene (Appendix 1).l        and Emira Biti Ghazali.


                             Tour of Hospital                               Putrajaya Hospital:
                                                                            Dr Vidja Natthondan (Infection Control)
                                                                            M-LM


4pm – 5pm                    Discussion on content of point prevalence      Dr Mohd Shah
MOH                          survey.                                        Dato' Dr. Noorimi, (Deputy Director General & Director
                                                                            of Medical Development)
                                                                            M-LM
5-8pm                        Documentation of a potential modification of
Hotel                        the surveillance system and instruction
                             manual.




        Malaysian National Nosocomial Infections Surveillance System                                                    34
        Annex 3: Time Frame continued



Friday 16th March 2007
8am – 3pm                    Discussion of workshop content and content         Dr Mohd Shah
MOH                          of focus discussion groups                         Dr HJH Kalsom Biti Maskon
4pm-7pm                                                                         M-LM
Hotel                        Development of modifications to the present        M-LM
                             surveillance system.
Saturday 17th March 2007     Develop the contents for         workshop focus    M-LM
3pm-9pm                      discussion groups
Hotel                        Develop    the    presentation     of   modified   M-LM
                             surveillance system.


Sunday 18th March 2007       Arrive Langkawi
K-L to Langkawi
Monday/Tuesday               Present two lectures on
19th-20th   March 2007            Strengths and Weaknesses of Surveillance Systems (using Australia/Overseas experiences) &
Microbiologists/Infectious        results of Malaysian prevalence surveys.
Diseases Physicians               Present MRSA and Hand Hygiene research.
                             Ran Focus Discussion Groups to identify key stakeholders’ opinions of current system, its limitations, and
Wednesday/Thursday           opinions about several possible modifications and beliefs about resources required to undertake
21st- 22nd March 2007        surveillance (Annex 5).
Infection Control Nurses




        Malaysian National Nosocomial Infections Surveillance System                                                        35
For Annexes 4, 5, 9, 10, 11, 12, 13, 14
and 15, please contact HSD Unit at
HSD_Unit@wpro.who.int




Malaysian National Nosocomial Infections Surveillance System   36
Annex 6. Focus Discussion Prompts for Doctors and Nurses to identify perceived
weaknesses and strengths of current surveillance system


Attendees will be placed in groups of around 10 members. The groups will discuss
selected questions and prepare to present their findings to the other groups during the
next 2.5 hours. A spokesperson for the group will have 10 minutes to present the group‟s
findings for a wider discussion with all the delegates.


Please discuss the questions below and at the end of each keep notes on your group‟s
answers:


Section 1 is about the current data collection


1a.     What surveillance data in the current survey are most useful for you to improve
        patient safety in terms of infection prevention and control?

1b.     What action do you take based on the current data?

1c.     If you don‟t react to the current data, why not?

1d.     Are there hospital organisational barriers that prevent you from reacting to
        the data?

1e.     If yes, what are they and what do you believe would help to remove these
        barriers?



Section 2 is about the future data collection.


Presently, data are collected using two point prevalence surveys with MRSA collected
continuously.


2a.     If you want the point prevalence survey to be changed to continuous surveillance
        what do you believe would improve for you? If not, why not?


        If the current use of two point prevalence surveys were to be continued:


2b.     What data should be removed from the survey? Why?


Malaysian National Nosocomial Infections Surveillance System                           37
2c.     What data are missing from the current point prevalence surveys that you believe
        should be included in future surveys that would assist you to improve to improve
        patient safety in terms of infection prevention and control?

2d.     How would you use these new data?



Section 3.


“At present the current point prevalence survey collects data to calculate the rates of
adverse outcomes. These rates are termed “Clinical Indicators” that aim to provide a
measure of the level of patient safety in terms of transmission of infection. Other indicators
that measure processes related to patient safety in terms of transmission of infection can
be as useful or more useful in providing administration and clinical staff with information
about where errors have occurred during recent periods of patient management. Two
pivotal activities of infection control are hand hygiene and judicious antimicrobial
prescribing. Both could be measured as a Process Indicator. Third generation
cephalosporins are one group of antibiotics associated with high resistance patterns. “


3a.     “If you were given the utilisation rate of 3rd generation cephalosporins and
        the resistance patterns, would you use these rates to influence prescribing
        patterns?”


        “Doctors and nurses are reluctant to tell their peers when they have not performed
        correct hand hygiene practices. If a hand hygiene audit during the point prevalence
        survey was performed after a one week „buddy week‟. This „hand hygiene buddy-
        week‟ would consist of all healthcare worker asked to choose a “hand hygiene
        buddy” for each shift. Their „buddy‟ is to remind their healthcare worker to hand
        hygiene when they forget. The next week an overt hand hygiene audit would take
        place by the link nurse and the infection control department will provide each ward
        with their rates. “


3b.     “Is it possible for link nurses to ensure hand hygiene buddies are identified
        by both nurses and doctors at the beginning of every shift?”


3c.     “Should we have a hand hygiene doctor on every ward to act as the link doctor?”



Malaysian National Nosocomial Infections Surveillance System                               38
      Annex 7. Nurse Focus Discussion Group Reporting Prior to Consensus

      Section 1: Nurses‟ Groups reporting on the Current Data Collection

Questions   Group 1                                        Group 2                                                            Group 3
1a          MRSA                                           MRSA K. pneumoniae                                                 MRSA
                                                                                                                              Antibiotic usage
                                                           Gram Negative E.coli, Pseudomonas, Acinetobacter                   All HAI- Point-prevalence survey

1b          Training/education                             MRSA –IC measures, Educate clinicians & patients,                  Aseptic technique
            Hand hygiene campaign                          House keeping                                                      Hand Hygiene
            Supervision                                    Environment – screen staff, check - sterilization, disinfection,   Education
            Feedback to HOD                                single use items
            Environmental hygiene                           Hand Hygiene
            Cleaning disinfection and sterilization         Antibiotic prescribing;
                                                           Check type and duration
                                                           Hand Hygiene

                                                           Education/training new and old staff
                                                           Restrict visitors to ICU
1c           Barriers - No resources, reliable data        NA                                                                 Yes


1d          Yes,                                           None                                                               Yes

1e.         Support from management                        NA                                                                 No isolation room & Environment – staff: Patient ratio
            ICN ratio                                                                                                          (shared cohorting ratio)
            Link Nurse added duty to them                                                                                     Attitudes/knowledge – support services staff, new nurses, doctors,
            Lack of material eg; computer, program                                                                            patient/relatives
            strictly adhere to antibiotic policy                                                                              Training
                                                                                                                              Administration.




      Malaysian National Nosocomial Infections Surveillance System                                                                                                                          1
      Section 2: Nurses‟ Groups reporting on the Future Data Collection

Questions Group 1                                            Group 2                                            Group 3
2a.       No                                                 No                                                 Yes, continuous surveillance.
          But continuous surveillance would improve
          data.
2b.       None                                               None                                               None
2c.       None                                               None                                               Control Charts
2d.       -                                                  N/A                                                Timely results for staff


      Section 3: Nurses‟ Groups reporting on the Measuring Important Infection Control Process

Questions    Group 1                     Group 2                                                                    Group 3
3a.          Give rate to IC Committee   Review policy and remind medical staff of guidelines.                      Antibiotic sensitivity & usage patterns by ward.
             (Director, Micro,                                                                                      Antibiotic restriction
             pathology) Give rates to                                                                               Call for the meeting. Involve the head of department concern.
             HOD to improve their use                                                                               Check data
             Ensure prescribing policy
             followed
3b           Yes but…                    Yes                                                                        Yes
3c           Yes                         Yes, consultant                                                            Yes
3d           Isolation,                  Separate equipment , maintain standard precaution                          Hand Hygiene
             Std precautions.            Practice proper aseptic technique no normal saline dressing for MRSA       Proper aseptic technique – lines, wound dressing, urinary catheter insertion
                                         wound                                                                      Antibiotic guidelines
                                         Education- awareness to all categories of staff                            Isolation room
                                         To screen patients especially high risk patients                           Overcrowding, bed spacing 1m
                                                                                                                    Search-&-Destroy – colonisation in HCW
                                                                                                                    Decrease hospitalisation
                                                                                                                    CME
3e           Was line in situ for too    Review I/V antibiotic pattern
             long?                       Revise antibiotic Rx - can it be convert to oral
                                         Date/time/site of insertion
                                         Line policy – use simple line, peripheral line within 72 hours


      Malaysian National Nosocomial Infections Surveillance System                                                                                                                             2
Questions   Group 1                      Group 2                                             Group 3
3f          HCW                          Nurses with infection avoid                         Infection control day/week. distribute pamphlets.
            knowledge/skills/attitudes   nursing patient
                                         Patient education
                                         Supply hand rub at bedside
                                         Signage for cohorted patients 100% cohort nursing
                                         isolation room
                                         Improve hospital facilities
                                         Reinforce on the standard of care/
                                         limit the patient movement
                                         Relatives education
                                         Audit 3rd gen use
3g          Education/training.                                                              1. Training
            Audit adherence to                                                               MOH to have training plan
            antibiotic policies.                                                             Send IC team to attachments to O/S placements
            HH Audit.                                                                        Core “IC team”
                                                                                             Post-basic training for ICP
                                                                                             2. Target surveillance at hospital level
                                                                                             3. Std definitions/methodology/core set of data




     Malaysian National Nosocomial Infections Surveillance System                                                                                3
        Annex 8. Doctors’ Focus Discussion Group Reporting Prior to Consensus
        Section 1: Doctors‟ Groups reporting on Current Data Collection

Questions     Group 1                                      Group 2                              Group 3                                    Group 4
1a            MRSA,ESB                                     MRSA and ESBL                        Alert micro-organism                       All HAI – point prevalence survey
                                                           K. pneumoniae
                                                                                                All HAI- Point-prevalence survey
                                                           Gram Negative E.coli,
                                                           Pseudomonas, Acinetobacter
1b            ICN reviews lab for MRSA, ESBL , MRO         MRSA – HH, IC measures, Educate      Present results to HOD                     Change Antibiotic prescribing patterns
                                                           clinicians & patients                Without action taken                       based on local antibiogram.
              ICN informs link nurse to take IC             ESBL – prescribing; usage (DDD)
                                                            of 3rd & 4th generation                                                        Minimise invasive procedures.
              Lab informs ICN & treating clinician.         cephalosporins & carbapenems.                                                  Day care procedures

                                                                                                                                           Stabilise patient’s comorbidities prior to
                                                                                                                                           procedure.

                                                                                                                                           Strengthen sterile technique - SSI rate used
                                                                                                                                           to encourage HH
1c             Clinicians don’t interpret or communicate   No action – rates not timely (2-3    Dept try analysis                          -
react          rates                                       months old)
                                                           No LIS
1d            Shortage of ICN/ doing other jobs            LIS                                  IC - not priority by Administrator.        ICP numbers too few
              Link nurse should concentrate on infection   Lack human resources                 HOD - not giving enough co-operation       IC Training Budget
              control jobs.                                                                                                                Equipment Budget e.g. surgical
                                                           Lack isolation room                  Credibility of the data questionable .     equipment/sterilisation & disinfection.
                                                                                                                                           Some ICP do not have computers.
                                                                                                                                           Dedicated IC team.
                                                                                                                                           Too few isolate room (1-2 in smaller
                                                                                                                                           hospitals).

1e.           -                                            Administration/Policy makers         Dedicated IC Dr where no ID Physician      -
                                                           involvement, stop well trained ICN   Written guide /protocol remedial action.
                                                           promotion transfer


        Malaysian National Nosocomial Infections Surveillance System                                                                                                                      4
      Section 2: Doctors„ Groups reporting on Future Data Collection
Questions Group 1                                     Group 2                            Group 3                                  Group 4
2a.       Yes, trends, get early warning for          No continuous surveillance         No, maintain Point Prevalence surveys    Yes, use targeted continuous
          prevention of outbreak                      Too Time consuming                                                          surveillance.
                                                      Lack of manpower
                                                      Should target SSI, CRBSI, VAP,
                                                      other high risk areas


2b.          None                                     Prevalence easy but annual not     Many data collected not analysed /       None
                                                      biannual                           presented -
                                                                                         e.g. antibiotics used
                                                                                         usefulness on certain data ? e.g. date
                                                                                         of lab result received, Section C + D-
                                                                                         are they being analysed?
2c.          None                                     Under-reporting, rates not         Under-reporting due to questionable      None
                                                      validated, not adjusted, can not   methodology for detecting NI
                                                      compare inter-hospital rates.

2d.          -                                                                           Analyse current data                     -

      Section 3: Doctors‟ Groups reporting on the Measuring Important Infection Control Process
Questions Group 1                                     Group 2                            Group 3                                  Group 4
3a.       Utilization rate of 3rd gen ceph. and      Resistance & utilization pattern.   Hospital-based informed guidelines.      Hospital-based information on
          resistance pattern data - Influence        Add 4th gen cephalosporins,         Process audit for appropriateness of     infection by organism.
          prescribing pattern                        Carbapenems, quinolones             antibiotic usage.
                                                                                                                                  Antibiotic sensitivity pattern.
3b           Not possible for every shift             Good in theory – will it be        Possible                                 Yes
             Limit to office hours                    Junior: Junior                                                              Nurse:nurse
                                                      Senior: Junior                                                              MD:MD
                                                      Senior: Senior                                                              Nurse:doctor only if doctors agree!
                                                      Hierarchy!



      Malaysian National Nosocomial Infections Surveillance System                                                                                                      5
     Section 3: Doctors‟ Groups reporting on the Measuring Important Infection Control Process
Questions Group 1                                     Group 2                                Group 3                                    Group 4
3c        Not enough doctors                           Role is ambiguous                     Not enough doctors                         No - link nurse can do the job providing
                                                       Role model doctor to be link doctor                                              link nurse is the senior nurse.
3d          Isolation/ 100% cohorting.                                                       Hand hygiene                               Good HH
            HH                                                                               Antibiotics follow SOP                     Isolation room
            Std precautions.                                                                                                            Proper aseptic technique – lines, wound
            Limit visitor.                                                                                                              dressing, urinary catheter insertion
                                                                                                                                        Antibiotic use
                                                                                                                                        Surveillance of MRSA with feedback
                                                                                                                                        CME
3e          Aseptic technique (?? All insertion                                              Aseptic technique (?? Insertion occur in   Management - good catheter care
            occur in theatre)                                                                theatre)                                   Avoid unnecessary usage
            Limit usage.                                                                     Management - PPE use                       Removal if not necessary
            Removal promptly.                                                                HH,                                        Types of catheter – antibiotic coated
                                                                                             Early detection MROs 
3f          Restriction of usage - specialist only.                                          Guidelines- specific to organism           Local antibiotic guidelines for specific
            If no duration specified –No supply                                                                                         local issues.
            (pharmacy to control).                                                                                                      & for specific infection e.g. ceftazidime
            Antibiotic according to sensitivity                                                                                         for pseudomonas/melioidiosis.
            Correct dosage                                                                                                              Good clinical/pharmacy/Microbiology IC
                                                                                                                                        team communication.
                                                                                                                                        Antibiotic audit., Antibiotic stewardship.
3g          Education/training.                                                                                                         1. Training
            Audit adherence to antibiotic policies.                                                                                     MOH to have training plan
            HH Audit.                                                                                                                   Send IC team to attachments to O/S
                                                                                                                                        placements
                                                                                                                                        Core “IC team”
                                                                                                                                        Post-basic training for ICP
                                                                                                                                        2. Target surveillance at hospital level
                                                                                                                                        3. Std definitions/methodology/core set
                                                                                                                                        of data



     Malaysian National Nosocomial Infections Surveillance System                                                                                                                    1

								
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