VICNISS Hospital Acquired Infection Surveillance...

VICNISS Hospital Acquired Infection Surveillance Annual Report 2008–09

2 VICNISS Hospital Acquired Infection Surveillance Annual Report 2008–09

VICNISS Hospital Acquired Infection Surveillance Annual Report 2008–09 3

VICNISS Hospital Acquired Infection Surveillance Report


Published by the Quality, Safety and Patient Experience BranchVictorian Government Department of HealthMelbourne, Victoria

© Copyright State of Victoria 2010

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

This document may also be downloaded from the Department of Health website at http://www.health.vic.gov.au/ideas/infcon and from www.vicniss.org.au.

Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.

Printed by [insert name and address of printer].

March 2010


The year in review

Welcome to the 2008-2009 Victorian Hospital Acquired Infection Surveillance System (VICNISS) annual report. The report summarises data related to healthcare-associated infections, causative organisms and compliance with infection prevention processes in Victorian acute-care public hospitals.

This is the first year we have reported data using the financial year format rather than in a calendar year format. This means that previously published annual rates will not compare directly with those in this report; however, data has been adjusted in this report to enable comparison.

During 2009 rates of Staphylococcus aureus in central line-associated bloodstream infections have fallen. There has also been an improvement in surgical antibiotic prophylaxis choice, timing and duration yet there is no consistent trend in surgical site infection rates. An improvement can also be seen for surgical antibiotic prophylaxis for common procedures in smaller (Type 2) hospitals.

Influenza vaccination rates continue to improve, and importantly this includes increased rates among clinical staff. Overall, there is an improvement in the rate of vaccination among medical and nursing staff from 34 per cent in 2005 to 41 per cent in 2008.

Long term renal dialysis patients have been the focus of a new surveillance activity. Early data show that the rate of bloodstream infections in this group are lower than international rates obtained using the same surveillance tools.

Monitoring of bloodstream infections and multi-resistant organism infections occurs in hospitals with less than 100 acute beds and means that we can report with confidence that these infections are uncommon in this group of hospitals.

The VICNISS surveillance project has invited private hospital participation and seven private hospitals have begun contributing data using the same methodology as our Type 1 public hospitals. This significant development is a further recognition of the importance of surveillance for high quality patient care, and as a means of promoting good healthcare outcomes.

The Victorian Department of Health (the department) requested that VICNISS Centre coordinate the hand hygiene (HH) program in Victoria. Austin Health developed the HH program that is now the model for the Australian Commission for Safety and Quality in Health Care (ACSQHC) Hand Hygiene Australia project. Future VICNISS reports will include data on hand hygiene compliance rates in Victorian Public Hospitals and healthcare-associated Staphylococcus aureus bacteraemia rates.


A pilot study examining a bundle of process measures aiming to reduce surgical site infections after colorectal surgery is near completion. This involved a successful collaboration with colorectal surgeons, anaesthetists and the infection prevention team at Southern Health. We hope to refine this bundle and offer it more widely to colorectal surgical teams.

VICNISS continues to contribute to state, national and international forums by presenting and publishing findings. In 2009, this included posters at the Annual Society for Hospital Epidemiology meeting in San Diego and the International Conference for Antimicrobial Agents and Chemotherapy in San Francisco.

Associate Professor Mike RichardsDirector, VICNISS Coordinating Centre


Contents

Acknowledgements 11

Developments over the past 12 months 12

Glossary 47

Appendix A: VICNISS Advisory Committee 51

Appendix B: VICNISS Coordinating Centre staff 53

Appendix C: Confidence intervals on charts 54


List of tables

Table 1 Peripheral venous catheter (PVC) use from 1 January 2005 to 30 June 2009 33

Table 2 Number of annual ’Internal’ surgical site infections for Type 2 hospitals 40

Table 3 Number of annual inherited surgical site infections for Type 2 hospitals 40

Table 4 Rates of outpatient haemodialysis events for the first year of data collection 2008 to 09 41

Table 5 Proportion of staff known to be immunised by major and minor staff groups, 2005 to 2008 42

Table 6 Overall proportion of staff immunised 2005 to 2008 42


List of figures

Figure 1 Annual intensive care unit central line-associated bloodstream infection rates for A1 and other hospitals 14

Figure 2 Frequency of causative organisms in intensive care unit central line-associated bloodstream infections – A1 hospitals 15

Figure 3 Frequency of causative organisms in intensive care unit central line-associated bloodstream infections – other hospitals 16

Figure 4 Neonatal intensive care unit central line-associated bloodstream infection rate and peripheral line-associated bloodstream infection rate – 1 July 2008 to 30 June 2009 17

Figure 5 Frequency of causative organisms in neonatal care unit central line-associated bloodstream infections 18

Figure 6 Frequency of causative organisms in neonatal care unit peripheral line-associated bloodstream infections 19

Figure 7 Annual coronary artery bypass grafts, deep and organ space surgical site infection rates by risk category 20

Figure 8 Annual colorectal surgical site infection rates by risk category 21

Figure 9 Annual Caesarean section surgical site infection rates by risk category 22

Figure 10 Annual hip arthroplasty deep and organ space surgical site infection rates by risk category 23

Figure 11 Annual knee arthroplasty deep and organ space surgical site infection rates by risk category 24

Figure 12 Annual frequency of causative organisms after coronary artery bypass grafts 25

Figure 13 Annual frequency of causative organisms after colorectal surgery 26

Figure 14 Annual frequency of causative organisms after hip arthroplasty 27

Figure 15 Annual frequency of causative organisms after knee arthroplasty 28

Figure 16 Surgical antibiotic prophylaxis compliance with guidelines: choice of antibiotics appropriate 30


Figure 17 Surgical antibiotic prophylaxis compliance with guidelines: timing of antibiotics appropriate 31

Figure 18 Surgical antibiotic prophylaxis compliance with guidelines: duration of antibiotics appropriate 32

Figure 19 Surgical antibiotic prophylaxis compliance with guidelines: choice of antibiotics appropriate 34

Figure 20 Surgical antibiotic prophylaxis compliance with guidelines: timing of antibiotics appropriate 35

Figure 21 Surgical antibiotic prophylaxis compliance with guidelines: duration of antibiotics appropriate 36

Figure 22 Annual MRSA infection rates for Type 2 hospitals by time of infection relative to time of admission 37

Figure 23 Annual rates of laboratory confirmed bloodstream infection in Type 2 hospitals detected 48 hours or more after admission 38

Figure 24 Annual rates of occupational exposures by exposure type for Type 2 hospitals 39


Acknowledgements

The VICNISS Coordinating Centre is fully funded by the Department of Health. We would like to extend our thanks to the hospital executives and executive sponsors for supporting the program.

A special acknowledgment is extended to all the infection control nurses and staff who participated in this surveillance activity. Their continuing support and commitment make this program successful, and this report possible.


Developments over the past 12 months

ICU validation The VICNISS Coordinating Centre completed a validation study of data collected on central line-associated bloodstream infection (CLABSI) in intensive care units (ICUs). This study identified some discrepancy in applying surveillance definitions for CLABSI when assessment by hospital infection control consultants was compared with an expert review. This research report was published in the Journal of Infection Control and Hospital Epidemiology (McBryde et al 2009).

Using results of this study, we explored the projected effect of revising the CLABSI case-definition to maintain consistency with the National Healthcare Safety Network (NHSN) methodology used in the United States. The definition change consisted of removing criterion 2b that is ‘common skin contaminant is cultured from at least one blood culture from a patient with an intravascular line, and the physician institutes appropriate antimicrobial therapy’. The main rationale for the revised definition was to reduce over reporting of coagulase negative Staphylococcal infections, some of which were not true infections. NHSN began using the revised definition in January 2008.

The projected outcomes show enhanced reliability of data when the revised definition is used and this will be an important step towards improving the validity of CLABSI surveillance.

SoftwareThe SHIINe surveillance software (Safer Hospitals Integrated Information Network) has been a major focus of work over the past 12 months. SHIINe is being progressively rolled out to Type 1 hospitals. This involves integration with patient information systems and other databases within the hospital. A software integration company will undertake the installation and integration of the SHIINe software.

Implementation of major information systems reforms, such as the replacement of patient administration systems at some hospitals, affected the time frame for the rollout of the SHIINe Project, which will continue in 2010.

We plan to develop a new module in the coming months due to the need for greater surveillance of significant organisms. This will allow hospitals to monitor particular organisms or groups of organisms and to generate reports on their prevalence.


Colorectal surgery projectIn 2008, VICNISS and Southern Health initiated a joint project aimed at reducing SSI infections after colorectal surgery. This project involved looking at modifiable peri-operative factors for which there is evidence that certain measures can reduce infections. Similar projects have proven to be successful in other parts of the world.

Five process measures have been developed aimed at avoiding hypothermia, maintaining systolic blood pressure, ensuring adequate oxygenation, correct administration of antibiotics, and glucose control for diabetic patients. The project involved an extensive education program and monitoring of the process indicators. The formal part of the project lasted for six months, but Southern Health continues to run the project. Data are currently being analysed. Project results will include a suite of educational materials and guidelines for other hospitals wishing to apply the process measures.

Private hospital surveillanceWhile VICNISS surveillance program focused on surveillance of HAI in public hospitals, private hospitals have frequently expressed an interest in VICNISS surveillance activities. After consultation with the department who provided funds for the further expansion of our program, seven larger private hospitals were invited and agreed to participate in VICNISS surveillance activities. These hospitals, with the support of the VICNISS coordinating centre (VCC) staff, have lodged annual surveillance plans and submitted data accordingly.

The department and VICNISS look forward to continuing working closely with the private hospital sector on this exciting and important initiative. Once the private hospitals surveillance program is fully established, VCC will be able to compare public and private hospital HAI rates. We anticipate that more private hospitals will be invited to participate in VICNISS surveillance activities in 2010.

Expansion of outpatient haemodialysis surveillanceThe haemodialysis surveillance program, which has been operating in Type 2 hospitals has been modified and expanded to include all hospitals and associated dialysis centres wishing to participate in this program. A number of different outcome events are monitored including hospitalisations, antibiotic starts, positive blood cultures, access associated bloodstream infection, local access infections and vascular access infections. Reporting began on 1 July 2008 and there are now over 40 dialysis units participating in the program. Our report includes data from this surveillance program.


Surveillance – collated results

This section presents data collected from Type 1 and Type 2 hospitals. The final section contains results where data from Type 1 and Type 2 hospitals have been combined (HCW influenza vaccination and haemodialysis events). Most data are presented annually since 2003; however, ICU data are only presented since July 2008 as the definition change at this time means previous data are not comparable.

Type 1 hospital dataIntensive care unit dataFigure 1: Annual intensive care unit central line-associated bloodstream infection rates for A1 and other hospitals

Figure 1 displays the annual central line-associated bloodstream infection rates in the group A1 hospitals (the larger medical–school teaching hospitals) and ‘other’ hospitals for the 12 months since the implementation of the definition change on 1 July 2008. As expected, the major impact of the change has been reporting of less coagulase-negative Staphylococcal (CNS) infections with an associated lowering of the rates in all hospitals. The previous definition was over inclusive of CNS infections, reporting many episodes that represented bloodstream contamination rather than true infection. The new definition may exclude some true bloodstream infections, but is a pragmatic compromise to allow consistent and simple data collection. Similar effects have been observed in other countries after implementation of the altered definition.

0

1

2

3

4

5

Other Hospitals2008/09 (n=18062)

A1 Hospitals2008/09 (n=28217)

Year and number of device days (n)

Rate

per

100

0 de

vice

day

s


Figure 2: Frequency of causative organisms in intensive care unit central line-associated bloodstream infections – A1 hospitals

Figure 2 represents the annual frequency of causative organisms in A1 hospital ICU CLABSIs. Note ‘n’ represents the number of infections with organism data. Not all hospitals submit organism data, hence ‘n’ does not equal the total number of infections represented by the rates displayed in Figure 1.

Figure 2 shows a reduction in reporting of infections caused by coagulase-negative Staphylococcus after the definition change. There is a downward trend in infections attributed to Staphylococcus aureus, but infections caused by Enterococci, while still relatively infrequent, appear to be on the increase. Vancomycin-resistant Enterococci are a major problem in many developed countries particularly with respect to ICU bloodstream infections.

0

20

40

60

80

100Staphylococcus aureus Serratia spp.Pseudomonas aeruginosaOther organism Klebsiella spp.Escherichia coliEnterococcus faeciumEnterococcus faecalisEnterobacter spp.Coagulase Negative StaphylococcusCandida spp.Candida albicansAcinetobacter spp.

2008/09(n= 73)

2007/08(n= 153)

2006/07(n= 108)

2005/06(n= 125)

2004/05(n= 133)

2003/04(n= 120)

2002/03(n= 76)

Year and number of infections (n)


Figure 3: Frequency of causative organisms in intensive care unit central line-associated bloodstream infection – other hospitals

Figure 3 represents the annual frequency of causative organisms in ‘other’ hospital (large but less specialised hospitals) ICU CLABSIs. Note ‘n’ represents the number of infections with organism data. Not all hospitals submit organism data, hence ‘n’ does not equal the total number of infections represented by the rates displayed in Figure 1. The number of infections for which we have pathogen data are relatively small. As in A1 hospital ICUs, there has been a decrease in reporting of infections due to coagulase negative Staphylococci, predominantly because of the definition change.

0

20

40

60

80

100Other organismStaphylococcus aureus (MRSA)Pseudomonas aeruginosaKlebsiella spp.Enterococcus faeciumEnterococcus faecalisCoagulase Negative StaphylococcusCandida spp.Candida albicans

2008/09(n= 24)

2007/08(n= 19)

2006/07(n= 25)

2005/06(n= 19)

2004/05(n= 24)

2003/04(n= 10)

Year and number of proceedures (n)


Neonatal intensive care unit dataFigure 4: Neonatal intensive care unit central line-associated bloodstream infection rate and peripheral line-associated bloodstream infection rate – 1 July 2008 to 30 June 2009

Figure 4 displays the bloodstream infections (BSI) in neonatal ICUs which are both central line-associated and peripheral line-associated. Rates are stratified by birthweight as babies with lower birthweights are generally considered to be at a higher risk of developing infection. This explains the downward trend seen in this figure, which represents data submitted from four hospitals. These rates have particularly wide confidence intervals reflecting the small pool of data available to calculate the rates.

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8

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Peripheral line Central line> 25001501-25001001-1500750-1000< 750

Birthweight category (grams)

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e da

ys


Figure 5: Frequency of causative organisms in neonatal intensive care unit central line-associated bloodstream infections

Figure 5 shows the causative organisms associated with central-line bloodstream infections in neonatal units for all birthweights combined. The same definition change was applied to these infections as to the adult ICU bloodstream infections and this explains the decrease in CNS infections seen in this figure.

Not all hospitals submit organism data, hence ‘n’ does not equal the total number of infections represented by the rates displayed in Figure 4.

0

20

40

60

80

100Other OrganismStaphylococcus warneriStaphylococcus hominisStaphylococcus epidermidisStaphylococcus capitisStaphylococcus aureusSerratia marcescensPseudomonas aeruginosaEscherichia coliEnterococcus faecalisEnterobacter cloacaeCoagulase Negative StaphylococcusCandida spp.Candida albicans

2008/09(n=20)

2007/08(n=42)

2006/07(n=51)

2005/06(n=28)

2004/05(n=32)



Figure 6: Frequency of causative organisms in neonatal care unit peripheral line-associated bloodstream infections

Figure 6 displays the annual frequency of causative organisms in neonatal peripheral line-associated bloodstream infections for all birthweights combined. Not all hospitals submit organism data, hence ‘n’ does not equal the total number of infections represented by the rates displayed in Figure 4.

0

20

40

60

80

100

2008/09(n=13)

2007/08(n=39)

2006/07(n=34)

2005/06(n=19)

2004/05(n=27)

Other OrganismStaphylococcus warneriStaphylococcus hominisStaphylococcus epidermidisStaphylococcus capitisStaphylococcus aureusSerratia marcescensPseudomonas aeruginosaEscherichia coliEnterococcus faecalisEnterobacter cloacaeCoagulase Negative StaphylococcusCandida spp.Candida albicans



Surgical site infection data Figure 7: Annual coronary artery bypass grafts, deep and organ space surgical site infection rates by risk category

Figure 7 displays the annual coronary artery bypass graft deep and organ space SSI rates since 2003. Six hospitals submitted data for this procedure until the beginning of 2008. In January 2009 two private hospitals began contributing to this dataset.

These infections (deep and organ space) are considered the most reliable for investigating time trends or performing comparisons as they rarely go undetected and patients are usually readmitted. There has been little change in infection rates in category 1, in which most patients fall. Although the risk category 2 rate has increased in the last year, there are no trends in these rates that would be considered statistically significant. This increase represents a general increase that cannot be attributed to one or two hospitals. VICNISS will continue to monitor these rates and to advise hospitals of unusually high rates.

0

1

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6

2008/09(n= 597)

2007/08(n= 490)

2006/07(n= 515)

2005/06(n= 455)

2004/05(n= 506)

2003/04(n= 531)

2002/03(n= 350)

2008/09(n= 1252)

2007/08(n= 1304)

2006/07(n= 1331)

2005/06(n= 1473)

2004/05(n= 1357)

2003/04(n= 1583)

2002/03(n= 1026)

Risk category 1Year and number of proceedures (n) by risk category

Risk category 2

Rate

per

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Figure 8: Annual colorectal surgical site infection rates by risk category

Figure 8 displays the annual colorectal surgery SSI rates since 2003. This procedure is classified as ‘dirty’ surgery and, it is expected, that higher rates of infection will be seen than for ‘clean’ surgery (such as joint replacements). These data include superficial as well as deep and organ space infections. As this figure shows rates are showing a decreasing trend. Although this trend is not statistically significant, it is encouraging, as VICNISS have been working with one of the major data contributors to reduce their rates of SSIs after colon surgery. Nine hospitals have submitted data for this procedure.

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25

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35

2008/09(n= 146)

2007/08(n= 109)

2006/07(n= 141)

2005/06(n= 164)

2004/05(n= 152)

2003/04(n= 52)

2008/09(n= 335)

2007/08(n= 278)

2006/07(n= 319)

2005/06(n= 344)

2004/05(n= 294)

2003/04(n= 120)

2008/09(n= 278)

2007/08(n= 242)

2006/07(n= 246)

2005/06(n= 257)

2004/05(n= 219)

2003/04(n= 138)

Risk category 0 Risk category 1Year and number of proceedures (n) by risk category

Risk category 2

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Figure 9: Annual Caesarean section surgical site infection rates by risk category

Figure 9 displays the Caesarean section SSI rates since 2003. The rates for risk category 0 (the largest category), were trending downwards but have shown a slight increase over the last two financial years. After a high rate in 2003, rates for risk category 1 vary markedly from year to year. The hospitals contributing data have changed in different years (more so than for other procedures), and those years with more substantial numbers of procedures would be expected to give a clearer picture of the infection rate. Twenty-eight hospitals have submitted data for this procedure including several private hospitals that began submitting data in 2009.

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10

2003/04(n= 2423)

2004/05(n= 3146)

2005/06(n= 3905)

2006/07(n= 3924)

2007/08(n= 3709)

2008/09(n= 3305)

2003/04(n= 322)

2004/05(n= 515)

2005/06(n= 563)

2006/07(n= 488)

2007/08(n= 722)

2008/09(n= 559)


Risk category 1

Rate

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Figure 10: Annual hip arthroplasty deep and organ space surgical site infection rates by risk category

Figure 10 displays the hip arthroplasty surgery deep and organ space SSI rates since 2003. There has been a marked decrease in infection rates in risk category 0 and there is a slight downward trend in risk category 1 that is encouraging. Note that there is an even spread of patients across these two risk categories. Twenty-five hospitals have submitted data for this procedure including several private hospitals that began submitting data in 2009.

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5

2008/09(n= 1817)

2007/08(n= 1558)

2006/07(n= 1431)

2005/06(n= 1393)

2004/05(n= 1067)

2003/04(n= 1064)

2002/03(n= 515)

2008/09(n= 1046)

2007/08(n= 973)

2006/07(n= 948)

2005/06(n= 979)

2004/05(n= 668)

2003/04(n= 695)

2002/03(n= 412)


Risk category 1

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Figure 11: Annual knee arthroplasty deep and organ space surgical site infection rates by risk category

Figure 11 displays the knee arthroplasty surgery deep and organ space SSI rates since 2003. No real trends are apparent and patients are spread evenly over these two risk categories. Twenty-five hospitals submitted data for this procedure including several private hospitals that began submitting data in 2009.

0

1

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3

4

5

2008/09(n= 1028)

2007/08(n= 837)

2006/07(n= 839)

2005/06(n= 777)

2004/05(n= 581)

2003/04(n= 503)

2002/03(n= 291)

2008/09(n= 852)

2007/08(n= 817)

2006/07(n= 741)

2005/06(n= 736)

2003/04(n= 564)

2002/03(n= 356)

2004/05(n= 538)


Risk category 1

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Surgical site infection pathogensFigure 12: Annual frequency of causative organisms after coronary artery bypass grafts

Figure 12 displays the frequency of causative organisms in SSIs after coronary artery bypass graft surgery. Staphylococcus aureus remains by far the most commonly found pathogen in these SSIs over the entire period. The mix of aerobic gram negative pathogens has changed a little, with less Acinetobacter infections reflecting a general reduction of this pathogen in major Victorian public hospitals in recent years. Serratia, Enterobacter, and Pseudomonas infections are among gram negative infections reported in the last three years, and awareness of this may help guide choice of surgical antibiotic prophylaxis.

Note ‘n’ represents the number of infections with organism data, including superficial infections. Consequently, ‘n’ does not equal the total number of infections represented by the rates displayed in Figure 7.

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60

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100Other OrganismStaphylococcus aureus Serratia spp.Pseudomonas aeruginosaProteus spp.Klebsiella spp.Escherichia coliEnterococcus faecalisEnterobacter spp.Coagulase Negative StaphylococcusCandida spp.Acinetobacter spp.

2008/09(n= 86)

2007/08(n= 66)

2006/07(n= 68)

2005/06(n= 79)

2004/05(n= 80)

2003/04(n= 87)

2002/03(n= 57)



Figure 13: Annual frequency of causative organisms after colorectal surgery

Figure 13 displays the frequency of pathogens responsible for surgical site infections after colorectal surgery. Staphylococcus aureus remains the most important pathogen, and results from more detailed studies show that methicillin-resistant S.aureus cause a substantial proportion of these infections. As anticipated in surgery on the bowel, gram negative and other bacteria that make up bowel flora are more frequently the cause of infections than in orthopaedic and cardiovascular ‘clean’ surgery.

Note ‘n’ represents the number of infections with organism data, including superficial infections. Thus, ‘n’ does not equal the total number of infections represented by the rates displayed in Figure 8.

0

20

40

60

80

100Other OrganismStreptococcus spp. (Group C & G)Staphylococcus aureusSerratia spp.Pseudomonas spp. :(other)Pseudomonas aeruginosaMorganella morganiiEscherichia coliEnterococcus spp.Enterococcus faeciumEnterococcus faecalisEnterobacter spp.Coagulase Negative StaphylococcusCitrobacter spp.Candida albicansBacteroides fragilisBacillus spp.Aeromonas hydrophilia GroupAcinetobacter spp.

2008/09(n= 40)

2007/08(n= 44)

2006/07(n= 47)

2005/06(n= 58)

2004/05(n= 58)

2003/04(n= 19)



Figure 14: Annual frequency of causative organisms after hip arthroplasty

Figure 14 displays the frequency of causative organisms in SSIs after hip arthroplasty. The most dominant organism is Staphylococcus aureus, although the percentage may be decreasing in recent years with an increasing percentage of infections caused by gram negative organisms. This may have implications for antibiotic prophylaxis.

Note ‘n’ represents the number of infections with organism data, including superficial infections. Hence, ‘n’ does not equal the total number of infections represented by the rates displayed in Figure 10.

0

20

40

60

80

100

2008/09(n= 67)

2007/08(n= 82)

2006/07(n= 97)

2005/06(n= 83)

2004/05(n= 58)

2003/04(n= 46)

2002/03(n= 32)

Other OrganismStaphylococcus aureus (MRSA)Pseudomonas aeruginosaEscherichia coliEnterococcus spp.Enterococcus faeciumEnterobacter spp.Coagulase Negative Staphylococcus



Figure 15: Annual frequency of causative organisms after knee arthroplasty

Figure 15 displays the frequency of causative organisms in SSIs after knee arthroplasty. Once again, the most common organism is Staphylococcus aureus, and this has remained reasonably constant over the entire period.

Note ‘n’ represents the number of infections with organism data, including superficial infections. Therefore, ‘n’ does not equal the total number of infections represented by the rates displayed in Figure 11.

0

20

40

60

80

100

2008/09(n= 33)

2007/08(n= 19)

2006/07(n= 38)

2005/06(n= 26)

2004/05(n= 21)

2003/04(n= 19)

2002/03(n= 17)

Other OrganismStreptococcus spp. (Group C & G)Streptococcus spp. (Group B)Staphylococcus aureus Pseudomonas aeruginosaCoagulase Negative Staphylococcus



Surgical antibiotic prophylaxis

Type 1 Surgical antibiotic prophylaxis Surgical antibiotic prophylaxis has been shown to be effective in reducing the incidence of surgical wound infections for many types of surgery. The measurement of compliance of surgical antibiotic prophylaxis against recommended guidelines is a common process measurement in many surveillance programs worldwide.

Reporting is based on three criteria, each of which is assessed separately:

• antibiotic choice• antibiotic timing• duration of antibiotics after surgery.

These elements are assessed against the Therapeutic Guidelines Antibiotic Version 13 (2006) and the guidelines from the National Surgical Infection Prevention Project in the United States.

When interpreting these reports the following important points should be taken into consideration:

• VICNISS surveillance collects basic antibiotic information only, and does not include comprehensive patient-level clinical information that may influence the individual clinician’s decisions on each of the above criteria. For example, no information is collected on allergies or co-morbidities that may influence antibiotic choice.

• The list of antibiotics recorded in the VICNISS database is limited and uncommonly used drugs not on this list may be recorded in the database as ‘other’, meaning the antibiotic choice cannot always be judged for concordance with the guidelines, even when information was provided by the hospital. These cases are reported as ‘unknown’.

For simplicity, surgical procedures are grouped: the cardiac group includes procedures such as coronary artery bypass graft surgery, heart valve replacement, and other cardiac surgery; orthopaedic includes knee and hip arthroplasty. These groups of procedures have identical recommendations for antibiotic prophylaxis and hence can be combined for reporting purposes. In some hospitals, documentation of antibiotic prophylaxis remains problematic, and in fact compliance may be better than shown here as procedures with no documentation are included in the denominators.

When reviewing the Type 1 charts, take into account that data from some procedures such as hysterectomy are heavily influenced by one or two hospitals that contribute most of the data. In this case, if one hospital is performing poorly, low compliance will be indicated in the charts. In addition, the number of hospitals contributing data for this activity can vary from quarter to quarter, in accordance with which activities are under surveillance.


Figure 16: Surgical antibiotic prophylaxis compliance with guidelines: choice of antibiotics appropriate

Figure 16 displays the aggregate six-monthly compliance rates for 2003 to 2009 for antibiotic choice in Type 1 hospitals. The compliance rates are based on the choice of antibiotics being considered either optimal or adequate for the specific surgical procedure. As is shown in this figure, there has been an overall improvement in compliance with guidelines for choice for all procedure groups except hysterectomy. Some of the apparent variation can be due to a single hospital either beginning or suspending surveillance on the particular procedure group as has occurred with hysterectomy. Compliance rates are generally best for cardiac and orthopaedic surgery. Rates of compliance have improved markedly for caesarean section and colon surgery but remain low for hysterectomy procedures.

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100OrthopaedicHysterectomyColon surgeryCholecystectomyCardiacCaesarean section

Jan-Jul2009

Jul-Dec2008

Jan-Jun2008

Jul-Dec2007

Jan-Dec2007

Jul-Dec2006

Jan-Jun2006

Jul-Dec2005

Jan-Jun2005

Jul-Dec2004

Jan-Jun2004

Jul-Dec2003

Jan-Jun2003

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Figure 17: Surgical antibiotic prophylaxis compliance with guidelines: timing of antibiotics appropriate

Figure 17 shows the aggregate six-monthly compliance rates for timing of administration of first dose from 2003 to 2009. As demonstrated in this figure there are improvements for colon surgery and for orthopaedic surgery, while cardiac compliance seems to have declined slightly. Some of this change may be explained by increased use of vancomycin, which requires prolonged infusion before the procedure. This may be more difficult to organise preoperatively, especially for patients admitted the day of surgery. The large amount of variability in compliance for both cholecystectomy and hysterectomy is largely explained by smaller numbers of participating hospitals and different hospitals contributing at different times. For example, the hysterectomy data for the period July to December 2006 is all from a single poorly performing hospital. The change in cardiac compliance is more concerning since the same hospitals have contributed apart from two private hospitals joining in 2009.

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Jan-Jul2009

Jul-Dec2008

Jan-Jun2008

Jul-Dec2007

Jan-Dec2007

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Jul-Dec2004

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OrthopaedicHysterectomyColon surgeryCholecystectomyCardiac

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Figure 18: Surgical antibiotic prophylaxis compliance with guidelines: duration of antibiotics appropriate

Figure 18 shows the aggregate compliance rates from 2003 to 2009 for duration of antibiotics. There has been a substantial improvement in compliance with recommendations for cessation of antibiotics for most groups of surgery since 2003. Compliance rates for hysterectomy are variable for reasons explained previously. The dip in compliance for cardiac surgery may be due to two hospitals beginning data submission in 2005.

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Jan-Jul2009

Jul-Dec2008

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OrthopaedicHysterectomyColon surgeryCholecystectomyCardiacCaesarean section

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Type 2 hospital data Process Indicators

Peripheral venous catheter useThe aim of this process indicator surveillance module is to help reduce the infection risk associated with the use of peripheral venous catheters (PVCs). This module is based on recommendations outlined in the Guidelines for the prevention of intravascular catheter-related infections from the Centers for Disease Control and Prevention (2002).

Table 1: Peripheral venous catheter (PVC) use from 1 January 2005 to 30 June 2009

Measurement (24 participating hospitals) Frequency

Total number of PVCs 2050

Removal or replacement within 96 hours 83.8%

Insertion site – upper limb 89.3%

Sterile dressing 95.3%

Documented daily inspection 84.9%

Removal reason- phlebitis 8.0%

Removal reason- Exit site infection 0.1%

Removal reason- Primary bloodstream infection 0.0%

Removal reason - Other 8.1%

Overall, compliance with process for this module is quite good, and hospitals are now notified if they do not meet compliance targets.

Type 2 Surgical antibiotic prophylaxis

For Type 2 hospitals, procedure groups are combined for routine reporting due to smaller numbers. Combining procedures for reporting does not create the same problems as when measuring infections, as this is a process not an outcome indicator, and all the procedures that are included should receive antibiotic prophylaxis in accordance with guidelines.

For this report, the aggregate data have been reported by procedure.


Figure 19: Surgical antibiotic prophylaxis compliance with guidelines: choice of antibiotics appropriate

In general, compliance for choice of antibiotic has increased but is more variable due to lower numbers of procedures as compared with Type 1 hospitals, and hospitals reporting sporadically. Compliance for orthopaedic surgery stands out as superior to that for any other procedure group. Compliance for hernia repairs has shown marked improvement due to the efforts of individual infection control staff known to have been active in this area.

0

20

40

60

80

100

Jan-Jun2009

Jul-Dec2008

Jan-Jun2008

Jul-Dec2007

Jan-Jun2007

Jul-Dec2006

Jan-Jun2006

Jul-Dec2005

Jan-Jun2005

OrthopaedicHysterectomyAppendicectomyHerniorraphyColon surgeryCholecystectomyCaesarean section

Time period

Perc

enta

ge


Figure 20: Surgical antibiotic prophylaxis compliance with guidelines: timing of antibiotics appropriate

Timing of antibiotics has shown some improvements overall, particularly for colon surgery, hernia repairs and appendicectomy although for orthopaedic data there has been a drop in compliance.

0

20

40

60

80

100

Jan-Jun2009

Jul-Dec2008

Jan-Jun2008

Jul-Dec2007

Jan-Jun2007

Jul-Dec2006

Jan-Jun2006

Jul-Dec2005

Jan-Jun2005

OrthopaedicHysterectomyAppendicectomyHerniorraphyColon surgeryCholecystectomy

Time period

Perc

enta

ge


Figure 21: Surgical antibiotic prophylaxis compliance with guidelines: duration of antibiotics appropriate

Once again, there has been overall improvement in compliance for duration, and this has occurred for all procedures.

0

20

40

60

80

100

Jan-Jun2009

Jul-Dec2008

Jan-Jun2008

Jul-Dec2007

Jan-Jun2007

Jul-Dec2006

Jan-Jun2006

Jul-Dec2005

Jan-Jun2005

OrthopaedicHysterectomyAppendicectomyHerniorraphyColon surgeryCholecystectomyCaesarean section

Time period

Perc

enta

ge


Outcome indicators

Methicillin-resistant Staphylococcus aureus (MRSA) infectionThis report provides an aggregate rate of MRSA infections for all Type 2 hospitals. The rates are stratified using the time the infection was detected; that is, within 48 hours or after 48 hours of admission to hospital. This was based on the assumption that those identified within 48 hours were not considered to be acquired at the reporting hospital. Rates are expressed as the number of MRSA infections per 10,000 occupied bed days.

Figure 22: Annual MRSA infection rates for Type 2 hospitals by time of infection relative to time of admission

This figure shows there is a much lower detection of MRSA in patients after 48 hours of hospital admission compared with detection of MRSA in the first 48 hours of admission. This shows a low rate of acquisition of MRSA in Type 2 hospitals, and suggests that much of the MRSA detected is a result of patients acquiring MRSA elsewhere prior to admission. These infections may be healthcare acquired at another facility or community acquired.

0

1

2

3

4

5

2004/05(n=310154)

2005/06(n=343800)

2006/07(n=298178)

2007/08(n=382731)

2008/09(n=365654)

Present on admission or < 48 hoursGreater than 48 hours

Year and number of accute occupied bed days (n)

Rate

per

10,

000

occu

pied

bed

day

s


Laboratory-confirmed bloodstream infections (>48 hours)This report provides an aggregate rate of primary laboratory-confirmed bloodstream infections (LC-BSIs) for all Type 2 hospitals. For this module only hospital-acquired infections are now reported; that is, those that occur 48 hours or more after admission to hospital. This was based on the assumption that those identified within 48 hours were not considered to be acquired at the reporting hospital.

Rates are expressed as the number of primary LC-BSIs per 10,000 acute occupied bed days.

Figure 23: Annual rates of laboratory confirmed bloodstream infection in Type 2 hospitals detected 48 hours or more after admission

This figure displays the very low rates of laboratory-confirmed bloodstream infections in Type 2 hospitals. The rate is known to increase with the size of the hospitals (data not shown), which may reflect increased complexity of patient mix and higher risk of BSI in larger hospitals. While the annual rate remains very low, there is some evidence that the rate has increased over the past few years.

0

1

2

3

4

5

2008/09(n=370160)

2007/08(n=406179)

2006/07(n=329233)

2005/06 (n=384116)

2004/05(n=369582)


Rate

per

10,

000

occu

pied

bed

day

s


Occupational exposuresThis report gives an aggregate rate of parenteral and non-parenteral occupational exposures involving acute patient sources.

Parenteral exposure is defined as the piercing of skin with a contaminated sharp. Contaminated sharp is defined as any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes and exposed ends of dental wires.

An exposure is classified as non-parenteral when the eye, mouth, other mucous membrane or non-intact skin contact with blood or other potentially infectious materials.

The rate is calculated by dividing the number of occupational exposures by the number of acute occupied bed days, and multiplying by 10,000. Therefore, the rate is expressed as the number of occupational exposures per 10,000 acute occupied bed days.

Figure 24: Annual rates of occupational exposures by exposure type for Type 2 hospitals

0

1

2

3

4

5

2008/09(n=399577)

2007/08(n=424825)

2006/07(n=351599)

2005/06(n=398259)

2004/05(n=178579)

Non-parenteral Human biteParenteral


Rate

per

100

0 oc

cupi

ed b

ed d

ays


Surgical infection report

This module is designed to identify unusual clusters of deep or organ space surgical site infections (SSIs) that might otherwise go unnoticed.

This report gives information on the total number of deep and organ space SSIs categorised by hospital size. It includes infections that are present at the time of hospital admission.

‘Internal’ infections include those where the surgery was performed at the reporting hospital. Inherited infections are those where the surgery was performed at another hospital. These are classified according to the size of the reporting hospital and not the hospital size at which the surgery was performed, as this is often unknown (or may have been a Type 1 hospital).

Note: this is not a rate but the number of infections identified. Therefore, comparison against the VICNISS aggregate or another hospital is not recommended as these figures do not take into account the number or complexity of procedures or patient mix at each site.

Table 2: Annual number of internal surgical site infections for Type 2 hospitals

Size Small Aggregate

Size Medium Aggregate

Size Large Aggregate

VICNISS Aggregate

2004–05 1 14 14 29

2005–06 0 15 18 33

2006–07 0 31 16 47

2007–08 0 14 32 46

2008–09 1 13 26 39

Table 3: Annual number of inherited surgical site infections for Type 2 hospitals

Size Small Aggregate

Size Medium Aggregate

Size Large Aggregate

VICNISS Aggregate

2004–05 4 4 15 23

2005–06 3 4 12 19

2006–07 2 4 22 28

2007–08 2 5 6 13

2008–09 1 1 11 13


The following reports combine data from both Type 1 and Type 2 hospitals

Outpatient haemodialysis eventsSince the last annual report, the outpatient haemodialysis module has been improved and expanded to include both Type1 and Type 2 hospitals. This was done in consultation with stakeholders including renal physicians and networks, and haemodialysis nurses. Like all of the Type 1 VICNISS modules, it is based on the CDC NHSN surveillance program.

Centres are reporting on hospitalisations, antimicrobial starts, vancomycin starts, positive blood cultures, access associated bloodstream infections, local access infections and vascular access infections in outpatients undergoing haemodialysis. Reports are stratified by the type of access and the denominator used is patient months by type of access. Rates are reported per 100 patient months.

Rates for the period since the start of surveillance on 1 July 2008 are reported below. The number of contributing dialysis centres is 44.

Table 4: Rates of outpatient haemodialysis events for the first year of data collection 2008 to 09

Access type

Rate per 100 patient months (95% confidence intervals)

Vascular access Patient months Hospitalisations Antibiotic starts Vancomycin starts

Positive blood cultures

Positive blood cultures exclud-ing contaminants

Access associat-ed Bloodstream infections

Local access infection

Vascular access infection

Arteriovenous fistula

6956 6.2 (5.6 – 6.8)

0.6 (0.5 - 0.9)

0.5 (0.3 – 0.6

0.2 (0.1 – 0.3

0.1 (0.0 – 0.2)

0.1 (0.0 – 0.2)

0.2 (0.1 – 0.3)

0.2 (0.1 – 0.3)

Arteriovenous graft

659 11.2 (8.8 – 14.1)

0.9 (0.3 – 2.0)

0.3 (0.0 – 1.1)

0.5 (0.1 – 1.3)

0.3 (0.0 – 1.1)

0.0 (0.0 – 0.6)

0.5 (0.0 – 1.3)

0.6 (0.2 – 1.6)

Permanent central line

1116 13.4 (11.4 – 15.8)

4.1 (3.0 – 5.5)

3.0 (2.1 -4.3)

2.7 (1.8 – 3.8)

1.0 (1.2 – 2.9)

1.8 (1.1 – 2.8)

1.3 (0.8 -2.2)

3.2 (2.3 – 4.5)

Temporary central line

39 0.0 (0.0 – 9.5)

0.0 (0.0 – 9.5)

0.0 (0.0 – 9.5)

0.0 (0.0 – 9.5)

0.0 (0.0 – 9.5)

0.0 (0.0 – 9.5)

0.0 (0.0 – 9.5)

0.0 (0.0 – 9.5)


Healthcare worker influenza vaccination reportAs part of the annual provision of influenza vaccine for healthcare workers in public acute-care hospitals by the department, each hospital is asked to report to VICNISS the total uptake rate and the uptake rate for different staff groups. Not all hospitals are able to report for the different staff groups; Table 5 shows the results for those hospitals that were able to provide data at this level of detail.

Table 5: Proportion of staff known to be immunised by major and minor staff groups, 2005 to 2008

Table 6: Overall proportion of staff immunised 2005 to 2008

Year (number of participating hospitals)

2005 (n=75) 2006 (n=83) 2007 (n=90) 2008 (n=98)

Proportion 37.8 41.1 45.2 48.3

The NHMRC recommends that all healthcare workers involved in direct patient care should be vaccinated. An increase in the total proportion of staff vaccinated against seasonal influenza has been seen over the four–year period that data have been collected. Most importantly, there has been a significant increase in the proportion of medical, nursing and allied health staff vaccinated. These staff groups are usually involved in direct patient care.

Major staff category

Minor staff category

2005 2006 2007 2008

Number of staff

Proportion vaccinated (%)

Number of staff

Proportion vaccinated

Number of staff


Number of staff


Clinical Medical 5410 29.7 7733 31.8 7984 34.1 9980 37.1

Nursing 19412 35.7 26566 39.2 24832 42.9 34434 44.2

Allied health 4529 46.0 6018 38.4 6683 47.4 10110 49.3

Other 7239 50.8 5566 51.3 6301 51.2 10724 55.0

Non clinical Non-clinical 5529 37.4 11485 46.7 9533 47.2 10931 46.7

Laboratory Laboratory 740 41.6 1021 52.2 1389 42.6 1829 50.4


Spreading the word about VICNISS

VICNISS Coordinating Centre staff have presented at a number of local, national and international conferences and had articles published in peer-reviewed journals.

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

Recent Publications1. Worth LJ, Bull AL, Thorpe SM, MJ R. Meeting national recommendations for

surgical site infection surveillance: examples and lessons from the Victorian Healthcare-associated Infection Surveillance System. Healthcare Infection. 2009;14:199–22.

2. Worth LJ, Brett J, Bull AL, McBryde ES, Russo PL, Richards MJ. Impact of revising the National Nosocomial Infection Surveillance System definition for catheter-related bloodstream infection in ICU: Reproducibility of the National Healthcare Safety Network case definition in an Australian cohort of infection control professionals. Am J Infect Control. 2009;37(8):643–8.

3. McBryde ES, Brett J, Richards MJ, Bull AL, Worth LJ, PL R. Validation of Central Line Associated Blood Stream Infection Intensive Care Unit Surveillance Data from a Statewide Surveillance System in Australia. Infect Control Hosp Epidemiol. 2009;30:1045–9.

4. McBryde ES, Kelly H, Marshall C, Russo PL, McElwain DLS, AN P. Using Samples to Estimate the Sensitivity and Specificity of a Surveillance Process. Infect Control Hosp Epidemiol. 2008;29:559–63.

5. Kelly H, Bull AL, Russo PL, ES M. Estimating sensitivity and specificity from positive predictive value, negative predictive value and prevalence: application to surveillance systems for hospital-acquired infections. J Hosp Infect. 2008;69:164–8.

6. Bennett NJ, Bull AL, Dunt DR, Motley JE, Russo PL, Spelman DW, et al. A users evaluation of a smaller hospital surveillance program. J Infect Control. 2008;36(10):761–3.

7. Russo PL, Gurrin LC, Friedman ND, Bull AL, Marasco S, Kelly H, et al. Interhospital comparisons of coronary artery bypass graft surgical site infection rates differ if donor sites are excluded. Infect Control Hosp Epidemiol. 2007;28(10):1210–2.

8. Richards MJ, PL R. Surveillance of hospital-acquired infections in Australia -- One Nation, Many States. J Hosp Infect. 2007;65 Suppl 2:174–81.


9. Friedman ND, Russo PL, Bull AL, Richards MJ, H K. Validation of coronary artery bypass graft surgical site infection surveillance data from a statewide surveillance system in Australia. Infect Control Hosp Epidemiol. 2007;28(7):812–7.

10. Friedman ND, Bull AL, Russo PL, Leder K, Reid C, Billah B, et al. An alternative scoring system to predict risk for surgical site infection complicating coronary artery bypass graft surgery. Infect Control Hosp Epidemiol. 2007;28(10):1162–8.

11. Friedman ND, Bull AL, Russo PL, Gurrin L, MJ R. Performance of the National Nosocomial Infections Surveillance risk index in predicting surgical site infection in Australia. Infect Control Hosp Epidemiol. 2007;28:55-9.

12. Bull AL, Bennett NJ, Pitcher HC, Russo PL, MJ R. Influenza vaccine coverage among health care workers in Victorian public hospitals. Medical Journal of Australia. 2007;186(4):185–6.

13. Bennett NJ, Bull AL, Dunt DR, Spelman DW, Russo PL, MJ R. The implementation of a pilot surveillance program for smaller acute care hospitals. Am J Infect Control. 2007;35:196–9.

14. Bennett NJ, Bull AL, Dunt DR, Richards MJ, Russo PL, DW S. The quality of data reported to a smaller hospital pilot surveillance program. Infection Control and Hospital Epidemiology. 2007;28:486–8.

15. Bennett NJ, Bull AL, Dunt DR, Gurrin LC, Russo PL, Spelman DW, et al. Bloodstream infection surveillance in smaller hospitals. Australian Infection Control Journal. 2007;12:45–7.

16. Bennett NJ, Bull AL, Dunt DR, Gurrin LC, Russo PL, Spelman DW, et al. Occupational Exposures to Blood-borne Pathogens in Smaller Hospitals. Infect Control Hosp Epidemiol. 2007;28:896–8.

17. Bennett NJ, Bull AL, Dunt DR, Gurrin LC, Russo PL, Spelman DW, et al. MRSA Infections in Smaller Hospitals, Victoria. Am J Infect Control. 2007;35:697–9.


Recent Presentations1. Worth LJ, Bull AL, Thorpe SM, MJ R. Meeting national recommendations for

surgical site infection surveillance: examples and lessons from the Victorian Healthcare-associated Infection Surveillance System. Healthcare Infection. 2009;14:199–22.

2. Worth LJ, Brett J, Bull AL, McBryde ES, Russo PL, Richards MJ. Impact of revising the National Nosocomial Infection Surveillance System definition for catheter-related bloodstream infection in ICU: Reproducibility of the National Healthcare Safety Network case definition in an Australian cohort of infection control professionals. Am J Infect Control. 2009;37(8):643–8.

3. McBryde ES, Brett J, Richards MJ, Bull AL, Worth LJ, PL R. Validation of Central Line Associated Blood Stream Infection Intensive Care Unit Surveillance Data from a Statewide Surveillance System in Australia. Infect Control Hosp Epidemiol. 2009;30:1045–9.

4. McBryde ES, Kelly H, Marshall C, Russo PL, McElwain DLS, AN P. Using Samples to Estimate the Sensitivity and Specificity of a Surveillance Process. Infect Control Hosp Epidemiol. 2008;29:559–63.

5. Kelly H, Bull AL, Russo PL, ES M. Estimating sensitivity and specificity from positive predictive value, negative predictive value and prevalence: application to surveillance systems for hospital-acquired infections. J Hosp Infect. 2008;69:164-8.

6. Bennett NJ, Bull AL, Dunt DR, Motley JE, Russo PL, Spelman DW, et al. A users evaluation of a smaller hospital surveillance program. J Infect Control. 2008;36(10):761–3.

7. Russo PL, Gurrin LC, Friedman ND, Bull AL, Marasco S, Kelly H, et al. Interhospital comparisons of coronary artery bypass graft surgical site infection rates differ if donor sites are excluded. Infect Control Hosp Epidemiol. 2007;28(10):1210–2.

8. Richards MJ, PL R. Surveillance of hospital-acquired infections in Australia -- One Nation, Many States. J Hosp Infect. 2007;65 Suppl 2:174–81.

9. Friedman ND, Russo PL, Bull AL, Richards MJ, H K. Validation of coronary artery bypass graft surgical site infection surveillance data from a statewide surveillance system in Australia. Infect Control Hosp Epidemiol. 2007;28(7):812–7.

10. Friedman ND, Bull AL, Russo PL, Leder K, Reid C, Billah B, et al. An alternative scoring system to predict risk for surgical site infection complicating coronary artery bypass graft surgery. Infect Control Hosp Epidemiol. 2007;28(10):1162–8.


11. Friedman ND, Bull AL, Russo PL, Gurrin L, MJ R. Performance of the National Nosocomial Infections Surveillance risk index in predicting surgical site infection in Australia. Infect Control Hosp Epidemiol. 2007;28:55–9.

12. Bull AL, Bennett NJ, Pitcher HC, Russo PL, MJ R. Influenza vaccine coverage among health care workers in Victorian public hospitals. Medical Journal of Australia. 2007;186(4):185–6.

13. Bennett NJ, Bull AL, Dunt DR, Spelman DW, Russo PL, MJ R. The implementation of a pilot surveillance program for smaller acute care hospitals. Am J Infect Control. 2007;35:196–9.

14. Bennett NJ, Bull AL, Dunt DR, Richards MJ, Russo PL, DW S. The quality of data reported to a smaller hospital pilot surveillance program. Infection Control and Hospital Epidemiology. 2007;28:486–8.

15. Bennett NJ, Bull AL, Dunt DR, Gurrin LC, Russo PL, Spelman DW, et al. Bloodstream infection surveillance in smaller hospitals. Australian Infection Control Journal. 2007;12:45–7.

16. Bennett NJ, Bull AL, Dunt DR, Gurrin LC, Russo PL, Spelman DW, et al. Occupational Exposures to Blood-borne Pathogens in Smaller Hospitals. Infect Control Hosp Epidemiol. 2007;28:896–8.

17. Bennett NJ, Bull AL, Dunt DR, Gurrin LC, Russo PL, Spelman DW, et al. MRSA Infections in Smaller Hospitals, Victoria. Am J Infect Control. 2007;35:697–9.


Glossary

Term Definition

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

Antibiotic prophylaxis Prophylaxis is the use of antibiotics to prevent infections at the surgical site.

ASA score American Society of Anesthesiology (ASA) score. This index is designed to preoperatively assess the patient’s overall physical status. The score ranges from 1 for a healthy patient to 5 for a patient who is not expected to survive 24 hours post-surgery.

Birthweight The first weight of the newborn.

Bloodstream infection (BSI)

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

Case A patient identified as having an infection.

CDC Centers for Disease Control and Prevention (United States).

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

Central line-associated bloodstream infection

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

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

Coronary artery bypass graft surgery

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

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

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

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

Group A1 hospitals Large tertiary teaching hospital.

Hip arthroplasty Surgery in which the diseased ball and socket of the hip joint are partially or completely removed and replaced with an artificial joint.


Hospital-acquired infection or nosocomial infection

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

Infection Invasion by, and multiplication of, pathogenic micro-organisms in a bodily part or tissue that may produce tissue injury and progress to disease.

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

Intravascular device The device used to administer a solution into a vein, such as the familiar IV drip.

Intravascular device related bloodstream infection

Bloodstream infection linked with the presence of an intravascular device.

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

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

Methicillin-resistant Staphylococcus aureus (MRSA)

A methicillin (antibiotic) resistant strain of Staphylococcus aureus.

Neonatal A baby within the first four weeks of birth.

NHSN A secure, internet-based surveillance system that integrates patient and healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion (DHQP) at CDC. The NHSN incorporates the former NNIS program (see below).

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

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


Occupied bed days (OBD)

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

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

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

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

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

Peripheral line-associated bloodstream infection

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

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

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

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

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

Process indicator An indicator that measures a process; for example, compliance with hand-washing guidelines.

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

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

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

Retrospective surveillance

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

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

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


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

Surgical site infection (SSI)

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

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

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

Transmission of infection Any mechanism by which an infection is spread.

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

Type 1 surveillance Surveillance activities designed for hospitals with more than100 beds.

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

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

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

Ventilator-associated pneumonia

Pneumonia that has been caused by the presence of the ventilator.

VICNISS Advisory Committee

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

VICNISS Coordinating Centre

A centre that is fully funded by the Department of Health that collects and analyses data from individual hospitals, and reports to participating stakeholders on aggregate, risk-adjusted, procedure-specific infection rates.

VICNISS Technical Advisory Group

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

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


Appendix A: VICNISS Advisory Committee

IntroductionThe Victorian Hospital-Acquired Infection Surveillance System (VICNISS) and Coordinating Centre were launched in August 2002 by the Department of Human Services (now the Department of Health).

VICNISS aims to:

• promote a standardised approach to HAI surveillance methods• provide aggregated risk-adjusted data on HAIs that will enable health

services and hospitals to undertake inter-hospital and international comparisons

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

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

• promote the integration of surveillance of HAI with routine data collection and continuous quality improvement systems, and strategic management planning for infection control

• promote consumer participation in the development of HAI performance measure reporting.

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


Members in 2009

Member Representing

Mr Matthew Richards Victorian Infection Control Professionals Association

Ms Sally Campbell Executive Director, Business Development and Corporate Secretary, Melbourne Health

Ms Sarah Gray Consumer

Mr Steven Peushel Consumer

Mr Clinton Dunkley VICNISS Coordinating Centre

Ms Bernadette Kennedy Senior Program Advisor, Infection Prevention, Department of Health

Mr Chris MacIsaac Victorian Regional Committee Joint Faculty of Intensive Care Medicine

Mr Matthew Mason Victorian Infection Control Professionals Association

Mr Deane Wilks Manager, Quality and Safety Programs, Department of Health

Mr Felix Pintado (Chair) Australian College of Health Service Executives

A/Prof Mike Richards VICNISS Coordinating Centre

Mr Simon Williams Royal Australasian College of Surgeons

Dr Rhonda Stuart Australian Society for Infectious Diseases


Appendix B: VICNISS Coordinating Centre staff

A/Prof Michael Richards MD, MB, BS, FRACP, Director

Mr Clinton Dunkley BN, Operational Director

Dr Ann Bull PhD, BSc (Hons), M App Epid, Epidemiologist

Mr Simon Burrell Database Manager

Ms Noleen Bennett RN, MPH, CNC Infection Control

Ms Claire Boardman RN, MPH, CNC Infection Control

Ms Judy Brett BN, RM, CNC Infection Control

Dr Leon Worth MB, BS, FRACP, Infectious Diseases Physician

Ms Ling Wang NET/SQL Programmer

Ms Kylie Berry Administrative Officer

Ms Megan Hardwick Data Entry and Administrative Assistant


Appendix C: Confidence intervals on charts

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

Example of a confidence interval

Confidence intervals provide a good idea of the true infection rate and are important to consider when interpreting these rates. They represent the lowest and highest values that the true rate is likely to be. An infection rate based on 10,000 surgical procedures that resulted in 1000 infections would be calculated to be 10 per cent, with upper and lower confidence intervals of 9.4 and 10.6 respectively. This means the true rate is highly likely to lie between 9.4 per cent and 10.6 per cent. The same infection rate of 10 per cent would also be calculated from a sample of 10 procedures with one infection, but the confidence interval would be 0.3–44.5 (meaning the true rate lies between 0.3 per cent and 44.5 per cent), which suggests the calculated rate of 10 per cent may be very different from the true rate. Generally, the larger the sample size, the better the estimate of the rate and thus the confidence intervals are narrower.


Abbreviations

A1 Hospital Large teaching hospital

AEP Appropriateness evaluation protocol

ASCTS Australasian Society of Cardiac and Thoracic Surgeons

CABGS Coronary artery bypass graft surgery

CLABSI Central line-associated bloodstream infection

‘the department’ Department of Health

HAI Hospital-acquired infection

ICU Intensive care unit

IT Information technology

LC-BSI Laboratory-confirmed bloodstream infection

LOS Length of stay

MRO Multi-resistant organism

MRSA Methicillin-resistant Staphylococcus aureus

NHMRC National Health and Medical Research Council

NICU Neonatal intensive care unit

NHSN National Healthcare Safety Network (United States)

NNIS National Nosocomial Infection Surveillance (United States)

NNL Neonatal unit surveillance

OBD Occupied bed days

PVC Peripheral venous catheter

RC Risk category

SSI Surgical site infection

VAP Ventilator-associated pneumonia

VCC VICNISS Coordinating Centre

VICNISS Victorian Hospital-Acquired Infection Surveillance System

VICNISS Hospital Acquired Infection Surveillance...

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