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Survellance & Statistics - 5 Acadmy
Survellance & Statistics - 5 Acadmy
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Device related infections
1- Short-duration central lines
- Short duration central lines are inserted <21-30 days for the purpose of
administration of medicine, fluids, and nutrition.
- Because they are invasive devices, they pose a risk of infection.
- Studies have shown that infection in short-duration devices is often caused by bacteria on the
skin invading along the outside of the catheter.
. Different types of infections are common:
1- Colonization of bacteria either on the outside or inside of the catheter may occur.
2- Localized infection at the insertion site involves swelling, erythema, and discharge.
3- Exit infection can occur where tunneled catheters exit the skin.
4- Tunnel infection occurs along the portion of the catheter that is tunneled under the
skin before entering a vessel.
5- Bloodstream infections may be related to a catheter infection, with the same microbe,
but they may occur as primary infections without evidence of local inflammation.
2- Long-term central lines
Long-term central lines are in place for >30 days and can cause a variety of
infections, usually from microbes entering the catheter and moving down the inside to the
bloodstream. There are 3 types of long-term central lines in common use
.1- Non-tunneled catheters consist of subclavian silicone or peripherally-inserted central
catheters (PICC)
. 2- Tunneled catheters usually are inserted between the nipple and the sternum and have
a Dacron cuff about 5 cm from the exit point. This cuff anchors the catheter to fibrous
tissue.
3- Implantable ports include a catheter and metal port, all inserted under the skin in a
subcutaneous pocket, usually in the upper chest but sometimes in the arm.
While infections may be similar to short-term central lines with the addition of port-pocket
infection, of added concern is the development of biofilms that adhere to the catheters,
leading to bloodstream infections and antibiotic resistance. The implantable port has a
lower rate of infection than other types of lines.
Ventilators
Mechanical ventilation carries a risk of respiratory infection and pneumonia;
usually from the patient’s own microbes. Some infections are related to trauma
and swelling that compromises tissue, resulting in aspiration of normal flora of
the oropharyngeal area, and/or inhalation of microbes in aerosol form.
Contaminated equipment may provide a reservoir for microbes, especially in
moisture-containing tubes, nebulizers, or other equipment. Additionally, the
ventilator essentially inoculates the respiratory tract with microbes.
Nebulizers have been related to significant numbers of infection because the
moist environment encourages colonization, especially if the nebulizers are
reused for more than 48 hours. Humidifiers are often added to ventilators, but
these tend to cause condensation in tubes, again providing fertile ground for
microorganisms, unless heat moisture exchangers, which recycle exhaled heat
and moisture, are used. Manual ventilator bags have been implicated in spread
of infection because the inside of the bag wasn’t sufficiently sterilized.
Urinary catheters
Urinary infections are the most common hospital-acquired
infection in both acute and long-term care facilities, almost always
caused by invasive devices, such as catheters and cystoscopes.
Most people with continuous catheter drainage are chronically
infected within 30 days. Catheters are frequently over-used and
left in for too long, increasing risk of infection. Infections have
occurred both in endemically and epidemically and may involve
local inflammation, abscess formation, and, in males, infection can
spread to the testes, prostate, and other reproductive organs.
Because urinary tract infections are routinely treated with
antibiotics, they have a role in increasing resistance of
microorganisms to treatment. Fungal infections have increased
markedly as a result. The urinary drainage bag serves as a
reservoir for microorganisms, which can be transmitted on the
hands of staff handling the bags. Contaminated bags can be
implicated in pseudo infections, where only the urine in the
.bag is infected
Determining facility-specific denominator data for device related infections
Selected device- The NaSH has
associated established
infections standardized
numerator/deno
minator formulas.
The device-
associated
formula:
Numerator
Patient days Denominator
Device days for selected event by
location (ICU type)
(Or by birth weight for high-risk
neonates)
Standardized definitions
CDC definitions
In 1988, the CDC established the “CDC Definitions for Nosocomial Infections” to
standardize reporting and obtain meaningful data for a national database. The
definitions include:
a) Infection site: For example, a urinary tract infection is coded as UTI and a
surgical site infection is coded as SSI.
b) Code: The site of infection is further coded according to the sub-type: SUTI,
systematic urinary tract infection: ASB, asymptomatic bacteriuria; and OUTI,
other infections of the urinary tract.
c) Definition: The definition of the infection outlines the criteria for inclusion
into a coded category. For example, UTI-SUTI (urinary tract infection—
systematic urinary tract infection) includes 4 different criteria. For example,
Criterion 1 is defined as:
1- Patient has at least 1 of the following signs or symptoms with no other
recognized cause: fever (>38C), urgency, frequency, dysuria, or suprapubic
tenderness AND patient has a positive urine culture, that is >105
microorganisms per cm3 of urine with no more than 2 species of
microorganisms.
Primary mechanisms
There are a number of mechanisms by which bacteria are resistant to
antibiotics. The antibiotic-bacteria combination, dosage, and duration of
therapy all affect the type of resistance. These resistant bacteria have genes in
their DNA or plasmids that control protective mechanisms:
a) Inactivation occurs when the bacteria secrete different enzymes that
chemically modify the antibiotics, such as penicillin and chloramphenicol. This
is the primary method of antibiotic resistance.
b) Alteration of blinding sites may involve changes removal of molecules
in the cell wall, preventing the antibiotics, such as vancomycin and methicillin,
from attaching to the bacteria.
c) Efflux pumps essentially are mechanisms in the bacteria that serve as
pumps to force antibiotics, such as tetracycline and quinolones, out of the cell.
d) Alteration of cell wall through alterations of proteins eliminates ports of
entry into the bacteria cell wall by decreasing permeability.
Bias
Selection bias occurs when the method of selecting subjects results in a
cohort that is not representative of the target population because of
inherent error in design. For example, if all patients who develop urinary
infections with urinary catheters are evaluated per urine culture and
sensitivities for microbial resistance, but only those patients with
clinically-evident infections are included, a number of patients with sub-
clinical infections may be missed, skewing the results. Selection bias is
only a concern when participants in studies are specifically chosen. Many
surveillance studies do not involve selection of subjects. Information bias
occurs when there are errors
Classification, so an estimate of association is incorrect. Non-differential
misclassification occurs when there is similar misclassification of disease or
exposure among both those who are diseased/exposed and those who are
not. Differential misclassification occurs when there is a differing
misclassification of disease or exposure among both those who are
.diseased/exposed and those who are not
Hospital reporting
There are a number of issues related to hospital reporting that can result
in inaccurate data.
1-Insufficient information may be the result of incomplete medical
records or lab reports at the time of survey. There may be a failure in the
reporting procedure so that some data is not reported.
2- Evaluation errors may occur even when data is available but is
overlooked or the significance is not understood so that the data is not
included in a survey.
3- Insufficient laboratory testing is a frequent finding of studies. Very
often indications of infection are clinically evident but cultures that would
verify infection are not ordered by the physician or are not automatically
triggered by established threshold rates.
4- Negligence may relate to reluctance to verify and report infections in
order to keep infection rates low.
Because of differences in efficiency of collecting data, the facility with the
lowest infection rate may be the one with the least accurate collection of
data.
Internal and external validity
Many surveillance plans are most concerned with internal validity,
adequate unbiased data properly collected and analyzed within the
population studied, but studies that determine the efficacy of procedures
or treatments, for example, should have external validity as well; that is,
the results should be generalizable (true) for similar populations.
Replication of the study with different subjects, researchers, and under
different circumstances should produce similar results. For various
reasons, some people may be excluded from a study so that instead of
randomized subjects, the subjects may be highly selected so when data is
compared with another population in which there is less or more
selection, results may be different. The selection of subjects, in this case,
would interfere with external validity. Part of the design of a study should
include considerations of whether or not it should have external validity
or whether there is value for the institution based solely on internal
validation.
Time-related risk and multiple events
Most studies of hospital-acquired infections involve time at risk rather
than patient numbers, so studies of incidence density related to invasive
devices, such as intravenous lines or urinary catheters, are often based
the number of infections per 1000 device days, that is days at risk. If there
are 200 patients with a total of 600 device days and 6 patients develop
infections, those 6 patients are no longer “at risk” because they have the
infection and become part of the numerator data (number of infections),
so their device days counted only up to the point where an infection is
diagnosed. Additionally, frequently the same patient may have multiple or
recurring infections, with the first infection a significant risk factor for the
second. Generally, first events only are included in the data to avoid
counting a subject more than once. Alternately, data may be stratified
according to the number of infections to calculate risks. Longitudinal
studies that account for multiple infections over time may also be
completed.
Using tables, graphs and charts to present reports
Presenting data in the form of charts and graphs provides a visual
representation of the data that is easy to comprehend. There are basically
3 types of graphs: line, bar, and pie.
Line graphs have an x and y axis, so they are used to show how an
independent variable affects a dependent variable. Line graphs can show
a time series with time usually on the x (horizontal) axis. This graph might
be used to show number of infections per week/month.
Bar graphs are used to compare and show the relationship between two or
more groups. The graphs can show quantifiable data as bars that extend
horizontally, vertically, or stacked. Bar graphs might be used to show
comparison data of different populations or to compare data from one time
period to another.
Pie charts are used to show what percentage an item is compared to the
whole. A pie chart can show distribution of infection control resources.
Coordinating and conducting investigations of
clusters of infection
Coordination and conduct of investigations of clusters or other adverse events
should be established as part of the surveillance plan so that any adverse
events trigger a chain of actions that may include the following:
Immediate report to the infectious disease professional/committee
Development of profile and definition of the outbreak with pertinent
information, such as place, time, and/or incubation period.
Statistical analysis of data to determine probability that adverse events
occurred by chance.
Additional laboratory specimens obtained or retesting done on existing
specimens. May include targeted cultures or serologic testing.
Review of medical records.
Contact staff, patients, physicians and public health officials as appropriate.
Identification of index case.
Review of the infection control process through interviews, review of written
policies and direct observation of staff procedures.
Assessment of source of infection and development of hypothesis with case
control or cohort study.
Notification of administration or management.
Epidemiologic studies
Case control and cohort studies
Case control studies compare those with infection (cases) to a group (controls)
without infection to determine if the infected group has characteristics that are
different from the control group. Case control studies are done retrospectively
backward from onset of infection to admission. Usually 2- 4 controls per case
are assessed although the larger the number, the more significant the results.
Controls should be chosen at random from the same source population of the
cases. Case control studies are relatively inexpensive and can quickly assess
risk factors during a possible outbreak, such as potential cause and effect;
however, case control studies do not prove causality because there can be
confounding variables. While case control studies cannot indicate relative risk,
they can be used to calculate the odds ratio, that is the estimate of relative risk.
Risk factors indicated by case control studies should be studied more
conclusively.
Cohort studies
A cohort study involves a group that is studied over time. There are a number
of subtypes. Prospective cohort studies choose a group of patients without
disease, assess risk factors, and then follow the group over time to determine
(prospect for) which ones develop disease. This is typical of general
surveillance studies for surgical site infections. Cohort studies take more time
but are more reliable statistically than case control studies. In another cohort
study, an exposed group and a non-exposed group may be followed to
determine how many develop a particular disease. Results are often
demonstrated in “2 x 2” tables that show presence of disease and
exposure/risk.
Totals No disease Disease
40 28 12 Exposure
60 58 2 Noexposur
e
100 84 4 Totals
Practice Test
Practice Questions
1. A hospital's infection control nurse reported postsurgical wound
infections by classification in a group of patients. Which was classified
correctly as clean-contaminated (class II)?
a. Closed reduction of Colles fracture in 74-year-old woman
b. Emergency appendectomy and abscess evacuation in febrile 18-year-old man
c. Elective thoracotomy with right upper lobectomy in 52-year-old smoker
d. Stab wound to abdomen with intestinal perforation in 25-year-old man
2. A comparison of the incidence of lung cancer in a population of
smokers compared with the incidence in a nonsmoking population defines
which statistical term?
a. Relative risk
b. Incidental risk
c. Disease prevalence
d. Disease incidence
3. A large community hospital's tumor registry reports a marked decrease in cases
of hepatocellular carcinoma over a 20-year period. Which of the following is LEAST
likely to account for this occurrence?
a. Improved serologic screening of transfusion donors
b. Higher vaccination rates for hepatitis A
c. Higher community vaccination rates for hepatitis B
d. Decreased prevalence of seropositivity for hepatitis C over same period
4. A male health care worker from the Philippines who is applying for a
surgery scrub tech position tests positive for hepatitis B surface antibody,
negative for hepatitis B e antigen (HBeAg), and negative for hepatitis B
surface antigen (HBsAg). Which is the best interpretation or
recommendation in light of these findings?
a. He is likely immunized to hepatitis B by prior vaccination.
b. He is likely to have chronic hepatitis B infection.
c. He is likely to be a carrier and should not be offered the surgical suite position.
d. He is likely to be highly infectious and should receive hepatitis B immune
globulin.
.