Indian Journal of Medical Microbiology IAMM  | About us |  Subscription |  e-Alerts  | Feedback |  Login   
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size
 Home | Ahead of Print | Current Issue | Archives | Search | Instructions  
Users Online: 8565 Official Publication of Indian Association of Medical Microbiologists 
  Search
 
  
 ~  Similar in PUBMED
 ~  Search Pubmed for
 ~  Search in Google Scholar for
 ~Related articles
 ~  Article in PDF (4,118 KB)
 ~  Citation Manager
 ~  Access Statistics
 ~  Reader Comments
 ~  Email Alert *
 ~  Add to My List *
* Registration required (free)  

 
 ~  Abstract
 ~ Introduction
 ~  Materials and Me...
 ~ Results
 ~ Discussion
 ~ Conclusion
 ~ Acknowledgments
 ~  References
 ~  Article Figures
 ~  Article Tables

 Article Access Statistics
    Viewed3763    
    Printed153    
    Emailed4    
    PDF Downloaded329    
    Comments [Add]    
    Cited by others 1    

Recommend this journal

 


 
  Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 33  |  Issue : 1  |  Page : 51-62
 

Device-associated infections at a level-1 trauma centre of a developing Nation: Impact of automated surveillance, training and feedbacks


1 Department of Laboratory Medicine, JPNA Trauma Centre, AIIMS, New Delhi, India
2 Department of Hospital Infection Control, JPNA Trauma Centre, AIIMS, New Delhi, India
3 Department of Forensic Medicine, JPNA Trauma Centre, AIIMS, New Delhi, India
4 Department of Surgery, JPNA Trauma Centre, AIIMS, New Delhi, India
5 Department of Anaesthesiology, JPNA Trauma Centre, AIIMS, New Delhi, India
6 Department of Neurosurgery , JPNA Trauma Centre, AIIMS, New Delhi, India
7 Department of Surgery; Department of Surgical Disciplines, JPNA Trauma Centre, AIIMS, New Delhi, India

Date of Submission07-May-2013
Date of Acceptance13-Mar-2014
Date of Web Publication5-Jan-2015

Correspondence Address:
P Mathur
Department of Laboratory Medicine, JPNA Trauma Centre, AIIMS, New Delhi
India
Login to access the Email id

Source of Support: This study was funded by a grant from the Indian Council of Medical Research. We acknowledge the financial suppor t of ICMR for the performance of this study, Conflict of Interest: None


DOI: 10.4103/0255-0857.148378

Rights and Permissions

 ~ Abstract 

Purpose: Device-associated infections constitute the majority of health care-associated infections (HAIs) in ICUs. Trauma patients are predisposed to acquire such infections due to various trauma-related factors. The prevalence of HAIs is underreported from developing nations due to a lack of systematic surveillance. This study reports the impact of an intensive surveillance on the rates and outcome of device-associated infections in trauma patients from a developing country and compares the rates with a previous pilot observation. Materials and Methods: The study was conducted at a level-1 trauma centre of India. Surveillance for ventilator-associated pneumonia (VAP), central line-associated blood stream infections (CLA-BSIs) and catheter-associated urinary tract infections (CA-UTIs) was done based on centre for disease control-National Healthcare Safety Network (CDC-NHSN) definitions. The impact of an intensive surveillance, education and awareness drive on the rates of infections over the study period, and compliance to preventive bundles and hand hygiene was assessed. Results: A total of 15,462 ventilator days, 12,207 central line days and 17,740 urinary catheter days were recorded in the study population. The overall rates of VAP, CLA-BSI and CA-UTI were respectively 17, 7.2 and 15.5/1000 device days. There was a significant correlation between device days and the propensity to develop infections. Infections were the cause of death in 36.6% of fatal trauma cases. A significantly higher rate of VAP, CLA-BSI and CA-UTIs was noted in fatal cases. The compliance to ventilator bundle, central line bundle, bladder bundle and hand hygiene were 74.5%, 86%, 79.3% and 64.6%, respectively. A high rate of multi-drug-resistance was observed in all pathogens. A gross reduction in the rates of all infections was observed over time during the study due to implementation of a stringent surveillance system, feedbacks and education. The compliance to hand hygiene and preventive bundles also increased over time. Conclusion: The automated surveillance was easy and useful for data entry and analysis. Surveillance had a significant impact on reduction of HAIs and mortality in trauma patients.


Keywords: Catheter-associated urinary tract infections, central line-associated blood stream infections, device-associated infections, ICU, ventilator-associated pneumonia


How to cite this article:
Mathur P, Tak V, Gunjiyal J, Nair S A, Lalwani S, Kumar S, Gupta B, Sinha S, Gupta A, Gupta D, Misra M C. Device-associated infections at a level-1 trauma centre of a developing Nation: Impact of automated surveillance, training and feedbacks. Indian J Med Microbiol 2015;33:51-62

How to cite this URL:
Mathur P, Tak V, Gunjiyal J, Nair S A, Lalwani S, Kumar S, Gupta B, Sinha S, Gupta A, Gupta D, Misra M C. Device-associated infections at a level-1 trauma centre of a developing Nation: Impact of automated surveillance, training and feedbacks. Indian J Med Microbiol [serial online] 2015 [cited 2019 Nov 19];33:51-62. Available from: http://www.ijmm.org/text.asp?2015/33/1/51/148378



 ~ Introduction Top


Health care-associated infections (HAIs) have become a global patient safety concern. [1] Device-associated infections (DAIs) like ventilator-associated pneumonia (VAP), central line-associated blood stream infections (CLA-BSIs) and catheter-associated urinary tract infections (CA-UTIs) together account for the majority of these infections. [2],[3],[4],[5],[6],[7],[8] DAIs have tremendous implications in terms of associated mortality, morbidity, increased cost of treatment, adverse patient outcomes and social impact. [9] Apart from the escalating rates, HAIs are now increasingly being caused by multi-drug-resistant organisms, which are difficult to treat due to paucity of new antimicrobials. [10]

Most of the data on the rates of DAIs are available from the developed countries, where a systematic surveillance for HAIs is routinely done. [9] In most developing nations, the priority given to prevention of HAIs is minimal and HAI prevention programmes are insufficiently funded by Governments. [11] Sustaining an efficient surveillance programme is a challenging task even in well-resourced settings and may often appear an unrealistic goal in developing countries. [2],[12],[13] In such a scenario, a targeted preventive approach, aiming at prevention of DAIs in the ICUs would be extremely beneficial and cost-effective. [14] For this, it is essential to initiate systematic surveillance, based on standard definitions.

Trauma centres in the developed countries usually report a higher prevalence of HAIs than other NHSN hospitals. [15] Ours is a 152-bedded, level-1 trauma care centre of India, the first in South Asia. This is the only Government sector hospital, having a fully functional Hospital and Laboratory Information Systems (HIS and LIS), where each patient is given a unique ID number. The Centre had no surveillance activity prior to January 2010, and had a high rate of antimicrobial-resistant infections. [10] An initial pilot observation was carried out from January to April 2010 to assess the baseline levels of HAIs. [16] Since then, we have initiated an electronic surveillance for DAIs, based on the centre for disease control (CDC)'s National Healthcare Safety Network (NHSN) updated definitions of HAIs. [17],[18] An indigenous hospital infection surveillance software has been developed, the first such initiative in the country, incorporating these definitions. In this study, we report the impact of an intensive surveillance, education and feedbacks on the rates of DAIs, mortality and the compliance to various preventive measures at a trauma centre of a developing nation by comparing the results with our pilot observation.

We hypothesised that a study on trauma victims would truly define the hospital variables predisposing to DAIs, as other risk factors are practically non-existent in this predominantly middle-aged population.


 ~ Materials and Methods Top


Hospital setting

The JPNA Trauma Centre is the first level-1 trauma centre of India, where patients from all over India are referred. The trauma centre is a part of the AIIMS hospital, which itself is a 2200-bedded, tertiary, referral and teaching hospital of India. Of the total 152 beds in the trauma centre, 32 are ICU beds. A total of six nurses function as full-time hospital infection control nurses (HICNs) for the 152-bedded centre. One microbiology resident and one data entry operator is specifically designated for hospital infection control work. All the patients who were admitted to the ICUs for more than 48 hours were included in the surveillance network.

The study reports the findings of the surveillance from June 2010 to September 2012.

Surveillance for DAIs

The data was collected daily, prospectively from each patient admitted to the ICU on specifically designed forms. Two HICNs are dedicated to this work to cover the 32 ICU beds. DAIs were defined according to the definitions provided by the CDC's NHSN [17],[18] [Table 1]. The surveillance forms were accordingly prepared and included basic demographic information, details of trauma and surgery, dates of insertion/change/removal of devices, presence of fever and recordings of vital parameters, length of stay, final outcome and cause of death (in case of fatal outcome). Since the DAIs were defined according to the CDC's definitions, for VAP, the following parameters were recorded daily (CDC's PNU 1 and 2 criteria): X-ray findings reported by a radiologist and confirmed by the clinician in-charge, TLC, characteristics of sputum, respiratory rate, gas exchange parameters, requirement for increased oxygen and microbiological culture report. Similarly, for CLA-BSI, the reports of blood culture, presence of chills, hypotension/hypothermia/fever/apnoea and bradycardia were noted daily. The forms were uploaded onto a specifically designed software program. All the medical, laboratory and radiological records were extracted from the HIS. The indigenous software has been named ASHAIN (an acronym for Automated Surveillance of Hospital Acquired Infections; Deft Infosystems Ltd, India), as shown in [Figure 1], [Figure 2], [Figure 3]. A designated data entry operator performed the data entry into the software for the sake of uniformity.
Figure 1: Algorithm for VAP diagnosis in our automated software-based surveillance system (ASHAIN)

Click here to view
Figure 2: Algorithm for CRBSI/CLABSI diagnosis in our automated software-based surveillance system (ASHAIN)

Click here to view
Figure 3: Proforma for monitoring bundle compliance in our automated software-based surveillance system (ASHAIN)

Click here to view
Table 1: CDC-NHSN definitions of device-associated infections

Click here to view


The admitted patients were followed for 48 hours after discharge from the ICUs to detect infections acquired in ICUs but manifesting only after transfer to other units.

Validation of reports

All the forms were validated by the clinicians and the microbiologists at the end of the month, in order to ensure that the CDC-NHSN criteria for defining HAIs were met.

Monitoring compliance to preventive bundles

The compliance to implementation of preventive bundles was monitored daily on a prescribed proforma, adapted from the Institute for Healthcare Improvement's (IHI) recommendations, [19],[20] [Figure 3]. The compliance rates were noted as the percentage of ICU patients with ventilators/central lines or urinary catheters, for whom all elements of the preventive bundles were compliant. If all the elements of the bundle were being implemented, the measure was included as compliant. The central line bundle consisted of the following elements: Hand hygiene, maximal barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection with avoidance of the femoral vein for central venous access in adult patients, and daily review of line necessity with prompt removal of unnecessary lines. The ventilator bundle consisted of: Elevation of the head of the bed, daily "sedation vacations" and assessment of readiness to extubate, peptic ulcer disease prophylaxis and deep venous thrombosis prophylaxis. The bladder bundle consisted of aseptic insertion and proper maintenance, condom or intermittent catheterization in appropriate patients, avoiding use of indwelling catheter unless absolutely essential and early removal of the catheter using reminders or stop orders, and dependent drainage. The compliance to preventive bundles was recorded by a HICN twice a week, during any shift. The central line bundle compliance was observed during the insertion and maintenance of central lines.

Monitoring compliance to hand hygiene

The observation was carried out by trained HICNs in the morning, evening and night shifts. For this, an extensive proforma was filled [Figure 4], [Figure 5], [Figure 6] for each health-care worker cadre who was present in the ICU during the observation time, as reported previously. [21] The observations were carried out twice a week in each ward for 1 hour. The proforma was devised according to the WHO's five moments of hand hygiene. Each opportunity was objectively marked as complied/not complied. The hand hygiene compliance is also monitored via CCTVs, the monitors of which are installed in the HIC room. Alcohol based hand-rubs were freely available on all bed-sides and nursing stations throughout. At the end of each month, the compliance status was reported as the percentage episode where hand hygiene was complied during patient care [Figure 7]. In addition, the number of bottles of hand rubs consumed in each ward was also compiled and reported [Figure 7].
Figure 4: Proforma for monitoring hand hygiene

Click here to view
Figure 5: Proforma for monitoring hand hygiene

Click here to view
Figure 6: Proforma for monitoring hand hygiene

Click here to view
Figure 7: Hand hygiene compliance evaluation in our automated software-based surveillance system (ASHAIN)

Click here to view


Calculation of rates, length of stay and mortality

The length of stay and mortality was noted prospectively daily while filling the patient's forms. The calculation of device days was done based on once daily prevalence measure as required by the NHSN. [17],[18] The DAI rates were calculated per 1000 device days. The crude mortality for DAI was calculated as the overall case-fatality of patients with a DAI. [9]

Monthly, ICU-wise reports regarding total number of admissions, device days, number of episodes of DAIs, rates of DAIs, compliance to hand hygiene and preventive bundle were prepared and sent to respective administrative heads and nursing superintendents. Feedbacks and suggestions regarding further necessary preventive actions were constantly provided to various clinical areas.

Training, education and feedbacks

All cadres of health care workers are given 1 week training on hospital infection control, hand hygiene and standard precautions. All new recruits of nursing staff are given weekly lectures for 3 months to cover all aspects of prevention of HAIs. The feedback for compliance to hand hygiene and preventive bundles are given monthly to the administrative head of the Centre, the nursing staff and all clinical faculties of the respective wards . We also undertake multiple training sessions on hand hygiene and preventive bundle practices for all cadres of health care workers. The house-keeping staff is trained in local language. We spread information by putting up hand hygiene and central line bundle posters on walls in all patient care areas. Videos are displayed regarding hand hygiene practices based upon WHO's five moments of hand hygiene in all clinical areas, serving as constant reminders. They are also supplemented by direct one to one reminders by our HICNs. Wards showing good compliance are given appreciation letters. All non-compliant health care staff members are personally informed about their non-compliant status.

Microbiological processing of samples

All samples for diagnosis of infections were sent by the treating clinicians, based on their clinical suspicion and criteria for diagnosis. The microbiological processing of specimens was done using standard methods. [22] The identification of all microbial isolates was done manually by standard microbiological methods [22] and by the Vitek-2 system (Biomerieux, France). The antimicrobial susceptibility testing was done by the disc diffusion technique according to the CLSI guidelines [23] and by the Vitek-2 susceptibility system (Biomerieux, France). Only those pathogens associated with nosocomial infections that met the CDC criteria were included in the database (i.e. patients who were colonised were not included in this study).

The cause of death in all fatal cases was recorded by the clinicians and since more than 95% of trauma patients are medico-legal cases, an autopsy is performed in all such fatal cases. The final cause of death is provided by the forensic experts on autopsy.

All parameters were compared with our pilot observation. Statistical analysis was done using Chi-square test with Yates correction.

The study was cleared by the Institutional ethics committee.


 ~ Results Top


The study was conducted over a 28-month period (June 2010 to September 2012). However, for the purpose of assessing the impact of the multi-modal infection prevention strategy on the rates of DAIs, the data was stratified into three time periods: The pilot study period (January-April 2010); [16] June 2010-August 2011; and September 2011-2012.

During the study period of June 2010 to September 2012, a total of 3341 patients were admitted to the ICUs of the trauma centre, amounting to a total of 25,290 patient days. A total of 2851 (85.3%) of them were males and 490 (14.6%) females. The age of these patients ranged from 1 month to 99 years, the median age being 31 years. Of these, 690 patients (21%) stayed in the ICUs for less than 48 hours and were therefore excluded from further analysis. The excluded patients were either admitted for post trauma observation/were post-operative and admitted for a short duration or were severely injured, who expired within 48 hours of admission.

Thus, a total of 2651 patients were followed up for DAIs. These patients amounted to a total of 24,122 patient days. The length of ICU stay of this study population ranged from 3 to 69 days (median 7 days). The age of the patients ranged from 1 month to 90 years (median 30 years). A total of 2267 (85.5%) patients were males.

Ventilator-associated pneumonia

The total ventilator days for these patients amounted to 15,462. A total of 264 episodes of VAP occurred during the study, amounting to a VAP rate of 17.07/1000 ventilator days. Of the 264 episodes, in 223 episodes (84%), a microbial aetiology was confirmed on quantitative culture of BAL/tracheal aspirates. In 41 episodes, either three types of microbes were obtained (35), or the samples grew insignificant counts of microbes (6). In our pilot observation, a total of 105 episodes of VAP were recorded in 2377 ventilator days. The comparison of VAP rates from January 2010 to September 2012 is shown in [Table 2]. A total of 259 pathogens were recovered from the 223 culture-confirmed episodes (distribution shown in [Table 3]).
Table 2: Trend of CLA - BSI and impact of preventive interventions from 2010 to 2012

Click here to view
Table 3: Distribution of organisms isolated from device-associated infections

Click here to view


Central line-associated blood stream infection

The total CVC days for the study population amounted to 12,207. A total of 88 episodes of CLA-BSIs occurred during the study, amounting to a CLA-BSI rate of 7.2/1000 CVC days. A total of 96 microbes were isolated from the 88 episodes of CLA-BSI [Table 3]. The comparison of CLA-BSI rates between the previous study (50 episodes in 1808 central line days) and the different periods of the present study is shown in [Table 2].

A total of 93 episodes of secondary BSIs were also observed during the study. Thus, we had an almost equal distribution of primary and secondary BSIs. Of these, 65 (70%) were secondary to VAP, 16 (17%) were secondary to wound infections and 12 (13%) were secondary to UTIs.

Catheter-associated UTI

The total urinary catheter days amounted to 17,740 in the study population. A total of 275 episodes of CA-UTI occurred in these patients, amounting to a CA-UTI rate of 15.5/1000 catheter days. A total of 295 organisms were isolated from these episodes of CA-UTI [Table 3]. The comparison of CA-UTI rates between the pilot observation (75 episodes in 2020 catheter days) and the present study is shown in [Table 2].

A consistent reduction in the rates of all DAIs was observed over the two time periods of the present study (June 2010-August 2011; and September 2011- 2012). The reduction in the rates of CLA-BSI, VAP and CA-UTI in the present study as compared to the pilot observation (January-April 2010) was statistically significant (P < 0.0001).

Correlation between device days and development of device-associated infections

[Table 4] shows the correlation between device days and predisposition for development of DAIs. There was a highly significant correlation between device days and development of DAIs. Thus, the 453 patients having ventilator days of >10 had a significantly higher rate of VAP (P < 0.0001), as compared to 2,198 patients having ventilator days <10. Similarly, the 355 patients having CVC days >10 and the 488 patients having urinary catheter days >10 had significantly higher rates of CLA-BSI (P < 0.0001) and CA-UTI (P < 0.0001) as compared to those having device days of <10.
Table 4: Correlation between device days and device - associated infections

Click here to view


Mortality

A total of 475 (18%) of the 2651 patients died during their ICU stay. An autopsy was performed on these cases. The recorded primary cause of death in these patients was severe injuries in 269 (56.6%), complications of trauma in 32 (6.7%) and infections in 174 patients (36.6%). A comparison of the percentage mortality in trauma patients and the contribution of infections as a cause of mortality during the present study and the same figures during January to April 2010 are shown in [Table 2]. Infections contributed to 60% of mortality in the pilot study as compared to 36.6% during the present study.

On overall analysis, 90 of the 264 episodes of VAP (34%), 29 of the 88 episodes of CLA-BSI (33%) and 83 of the 275 episodes of CA-UTI (30%) observed in the present study population occurred in the 475 patients who had a fatal outcome. [Table 5] shows the difference in infection percentages between fatal and non-fatal cases. A significantly higher rate of VAP, CLA-BSI and CA-UTI was noted in fatal cases.
Table 5: Comparison of infection percentage between fatal and non - fatal cases

Click here to view


Compliance to preventive bundles

The compliances to ventilator bundle, central line bundle and bladder bundle were 74.5%, 86% and 79.3%, respectively. The compliance to hand hygiene was on an average 64.6%. The corresponding compliance rates during our pilot study (from January to April 2010) were 10%, 32%, 6% and 8.4% for the ventilator, central line and bladder bundle and for hand hygiene, respectively [Table 2].

Antimicrobial susceptibility

A total of 650 clinical isolates were recovered from all DAIs reported in the study [Table 3]. All the genera showed high levels of multi-drug resistance. All the Gram-negative bacteria were sensitive to polymyxin (except the ones intrinsically resistant). However, the sensitivity to piperacillin/tazobactam (37%), gentamicin (8%), imipenem (50%), ciprofloxacin (4%), ceftazidime (5%), ceftriaxone/sulbactam (17%) and tigecycline (56%) was low. Amongst Staphylococcus sp., the sensitivity to ampicillin (8%), amikacin (9%), ciprofloxacin (8%), septran (3%), erythromycin (6%), clindamycin (14%) and rifampicin (33%) was low. All the strains were sensitive to linezolid and vancomycin.


 ~ Discussion Top


In contrast to the rates of HAIs varying from 5% to 10% in industrialised world, those in developing nations of Asia, sub-Saharan Africa and Latin America may be as high as >40%. [1],[13],[16],[24],[25] Although evidence-based guidelines are increasingly being implemented in the developed countries, many of the developing countries still lack basic health care facilities (HCFs), surveillance networks and resources to curtail HAIs. Minimal priority is given to HAIs due to inadequate trained manpower, lack of funds, lack of legislations mandating accreditation of hospitals and a general tendency of non-compliance towards basic infection control protocols. [2],[26] Due to lack of standardised surveillance, limited data on HAI is available from developing countries. Systematic surveillance is limited to a few multi-national studies conducted under the auspices of the International Nosocomial Infection Control Consortium (INICC). [8]

We initiated a pilot observation, during which we found high rates of all DAIs and extremely low rates of compliance to preventive bundles. [16] In the subsequent months, an indigenous software program was developed, which gave us graphic reports of monthly rates, which were distributed to the administrators and clinical units. An intensive training and sensitization drive was performed, covering all cadres of health care workers. Apart from this, posters were pasted all over the centre as reminders for hand hygiene. Preventive bundles were implemented and supervised. Free availability of alcohol-based hand rubs was made. Data analysis by software significantly reduced the manual time for report generation. It also helped us in following the impact of training, surveillance and interventions on the rates of DAIs, identification of cluster of cases and data stratification according to pathogens, trauma units, type of trauma etc.

During this study, we found reductions in the rate of all DAIs from April 2010 to September 2012. Since our methodology has remained the same, we feel this is due to the intensive surveillance, along with active interventions being carried out. Although the rates have reduced, they are still high as compared to the western ICUs. In general, trauma care ICUs report a higher rate of VAP than other ICUs. [15] In a multi-centric analysis of trauma ICUs in the USA, the pooled mean VAP rate was 17.2 versus 8.1/1,000 ventilator days for NHSN (2006-2008 report). [15] The rate of VAP in developing countries range from 10 to 41.7/1000 ventilator days. [27] VAP accounted for 41% of all DAIs in a multinational study conducted by the INICC in 55 ICUs. [8] The crude unadjusted mortality of HAP was 27.5% in study covering 98 ICUs of developing countries. [28]

The CDC recommended diagnostic algorithm for diagnosis of VAP begins with a suggestive chest X-ray finding. [17],[18] In our experience, the interpretation of chest X-rays was the most difficult part. In patients with chest or multiple trauma, X-ray findings of atelectasis and haemorrhages frequently mimics infiltrates. Moreover, due to multiple injuries, often a portable chest x-ray film is obtained rather than PA and lateral view, which requires transporting a patient to radiology facility. [29] Of the other parameters, fever and leucocytosis were generally present due to trauma-related factors also. Thus, recording of worsening gas exchange was the easiest to interpret in our patients.

A significant achievement of our study was our ability to reduce CLA-BSI rates. We feel that this is particularly due to the designation of one nurse and a resident for following up all BSIs and actively managing all such cases. We found an almost equal distribution of primary and secondary bacteraemia. According to the NHSN, the median rates of CVC-associated bacteraemia in ICUs ranged from 1.8 to 5.2/1000 CVC catheter days. [30] In a multinational study conducted by the INICC, the incidence of CVC-related BSIs was 12.5/1000 catheter days. [8] In trauma patients, since many central line insertions are carried out in emergency, strict aseptic precautions are often neglected. [29] Moreover, haemodynamic instability, and the need for repeated blood transfusions necessitate insertion of CVCs for long duration, apart from themselves acting as a risk factor for infections. Many a times, it is difficult to change the site of CVCs due to severe haemodynamic instabilities. [29]

We have found an increase in compliance to all preventive bundles and hand hygiene, which we believe was a major contributor to reduction of all DAIs.

Our study population was essentially middle-aged males. Severely traumatised patients are usually on multiple devices and present therapeutic challenges due to their inability to move (spinal, pelvic and polytrauma and presence of drains and dressings). Trauma to the chest often impairs chest physiotherapy. [29] The significant association between device days and development of DAIs in our study suggests that the devices should be promptly removed/changed.

A reduction in mortality and infections as cause of mortality was observed in our study. Since mortality and the autopsy-proven cause of death is a realistic indicator of change in the prevalence of HAIs, our data strongly supports the finding that as compared to our initial pilot observation, we have been able to accomplish a significant reduction in HAIs due to augmentation of surveillance, training and feedbacks.

High rates of antimicrobial resistance was observed in this study, which is similar to our previous observation on a large collections of clinical isolates from trauma patients. [10]

In most Indian hospitals, HAIs are documented by merely compiling microbiological data with minimal element of clinical data entry. Thus, systematic surveillance is essential for developing nations to make a start in curbing this growing health care burden. The hospital infection control programme at our centre is heavily dependent on this surveillance system. The sustainability this programme requires continuous training of staff. We can also carry this activity because of six full-time HIC nurses who are trained to carry out surveillance.

We found that software-based entry and analysis, based on standard definitions was easy to implement and also facilitated accurate generation of results. We also have an optimum HICN/patient bed ratio, which is helping us in doing this extensive daily survey. Such electronic surveillance systems are needed across the country to ultimately gauge the true magnitude of HAIs and plan comprehensive strategies for prevention and control. The cost of developing this software was approximately Rs 95,000 (~ $1900), which is quite nominal even for developing nations, considering the impact in reduction of infections. Till now there has been no maintenance cost except for down time of the intranet of the centre.

We envisage that this initiative can be extended to other Government-run hospitals, considering the implications of HAIs and the cost-effectiveness and efficiency of electronic surveillance.

Limitations of the study

The development of this system has not been without troubleshooting especially during the trial phase of implementation of diagnostic algorithm for VAP, which still requires manual checking of proformas at times. A lacuna of this study is that we have not evaluated the outcome of individual infections, length of stay and cost of treatment. This will be now included in the surveillance. Another limitation of the study could be inter-observer bias in recording data during surveillance activities. We have tried to overcome this inter-observer variation by giving prior training and regular monitoring of the surveillance data collection and entry by the hospital infection control staff, based on established guidelines. We have tried to make the designated surveillance proforma as objective as possible, so that it can be easily filled by a trained healthcare staff. These practices would help in reducing the human error in surveillance and data collection to the minimum possible extent.

The software is based strictly on standard definitions. Therefore, with changes in definition, the changed algorithm would have to be fed. Since this was probably the first such initiative to automated surveillance, we stuck to the standard guidelines proposed by the CDC. As more data is generated from India and country-specific alterations in diagnostic protocols are proposed, we would see if the algorithms can be suitably altered for our system. We feel that implementation of such system requires an initial effort during development and initiation. However, data retrieval and analysis becomes very easy with time, making it a reasonably low-cost monitoring system.


 ~ Conclusion Top


Systematic surveillance of device-associated infections has facilitated a reduction in the rates of DAIs and an increased compliance to preventive bundles and hand hygiene. Identification of priority areas, focused interventions and prompt information dissemination have aided in this reduction.


 ~ Acknowledgments Top


We acknowledge the technical help provided by Ms. Neelu, Ms. Rajrani, Mr Pawan, Mr Tirlok and Mr Vineet.

 
 ~ References Top

1.
WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge. "Clean Care is Safer Care". WHO Hand Hygiene.  Back to cited text no. 1
    
2.
McFee RB. Nosocomial or Hospital acquired infections: An overview. Dis Mon 2009;55:422-38.  Back to cited text no. 2
[PUBMED]    
3.
Pittet D, Harbarth S, Ruef C, Francioli P, Sudre P, Petgnat C, et al. Prevalence and risk factors for nosocomial infections in four university hospitals in Switzerland. Infect Control Hosp Epidemiol 1999;20:37-42.  Back to cited text no. 3
    
4.
Marik PE. Fever in the ICU. Chest 2000;117:855-69.  Back to cited text no. 4
    
5.
Durlach R, Mcllvenny G, Newcombe RG, Reid G, Doherty L, Freuler C, et al. Prevalence survey of health care associated infections in Argentina: Comparison with England, Wales, Northern Ireland and South Africa. J Hosp Infect 2012;80:217-23.  Back to cited text no. 5
    
6.
Raffaldi I, Scolfaro C, Pinon M, Garazzino S, Calitri C, Peretta P, et al. Surveillance study of healthcare associated infections in a pediatric neurosurgery unit in Italy. Pediatr Neurosurg 2011;47:261-5.  Back to cited text no. 6
    
7.
Kollef MH. Prevention of ventilator associated pneumonia or ventilator associated complication: A worthy, yet challenging goal. Crit Care Med 2012;490:271-7.  Back to cited text no. 7
    
8.
Rosenthal VD, Maki DG, Salomao R, Moreno CA, Mehta Y, Higuera F, et al. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med 2006;145:582-91.  Back to cited text no. 8
    
9.
Kanji SS, Kanafani ZA, Sidani N, Alamuddin L, Zahreddine N, Rosenthal VD. International Nosocomial Infection Control Consortium findings of device- associated infection rates in an intensive care unit of a Lebanese University hospital. J Glob Infect Dis 2012;4:15-21.  Back to cited text no. 9
    
10.
Behera B, Das A, Mathur P, Kapil A. High prevalence of carbapenem resistant Pseudomonas aeruginosa at a tertiary care centre of north India. Are we under- reporting? Indian J Med Res 2008;128:324-5.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Ponce-de-Leon-Rosales S, Macias A. Global perspectives of infection control. In: Wenzel RP, editor. Prevention and control of nosocomial infections. 4 th ed. Philadelphia: Lippincott Williams and Wilkins; 2003. p. 14e33.  Back to cited text no. 11
    
12.
Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, et al. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 2008;68:285-92.  Back to cited text no. 12
    
13.
Raka L. Lowbury Lecture 2008: Infection control and limited resources e searching for the best solutions. J Hosp Infect 2009;72:292-8.  Back to cited text no. 13
    
14.
National Nosocomial Infections Surveillance System. Nosocomial infection rates for interhospital comparison: Limitations and possible solutions. Infect Control Hosp Epidemiol 1991;12:609-21.  Back to cited text no. 14
    
15.
Michetti CP, Fakhry SM, Ferguson P, Cook A, Moore FO, Gross R, et al. Ventilator associated pneumonia rates at major trauma centres compared with a national benchmark: A multi-institutional study of AAST. J Trauma 2012;72:1165-73.  Back to cited text no. 15
    
16.
Gunjiyal J, Thomas SM, Gupta AK, Sharma BS, Mathur P, Gupta B, et al. Device associated and multidrug -resistant infections in critically ill trauma patients: Towards development of automated surveillance in developing countries. J Hosp Infect 2011;77:176-7.  Back to cited text no. 16
[PUBMED]    
17.
Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care associated infections and criteria for specific types of infection in acute care setting. Am J Infect Control 2008;36:309-32.  Back to cited text no. 17
    
18.
CDC. National Healthcare Safety Network. Device Associated Infections Module. Protocols and Instructions, 2010. Available from: http://www.cdc.gov/nhsn/psc_da.html. http://www.cdc.gov/nhsn/library.html. [Last accessed on 2013, Nov 22].  Back to cited text no. 18
    
19.
Zilberberg MD, Shorr AF, Kollef MH. Implementing quality improvements in the intensive care unit: Ventilator bundle as an example. Am J Infect Control 2009;37:172-5.  Back to cited text no. 19
    
20.
Institute for Health care Improvement. Available from: http://www.ihi.org. [Last accessed on 2013, Nov 22].  Back to cited text no. 20
    
21.
Mathur P, Jain N, Gupta A, Gunjiyal J, Nair S, Misra MC. Hand hygiene in developing nations: Experience at a busy, level 1 Trauma Centre in India. Am J Infect Control 2011;39:705-6.  Back to cited text no. 21
[PUBMED]    
22.
Collee JG, Diguid JP, Fraser AG. Mackie and McCartney practical Medical Microbiology. 14 th ed. Edinburgh: Churchill Livingstone; 1996.  Back to cited text no. 22
    
23.
Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing, 19 th Informational Supplements, 2009;M100-S16. CLSI 2006, Wayne, PA, USA.  Back to cited text no. 23
    
24.
Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate, a need for vital statistics. Am J Epidemiol 1985;121:159-67.  Back to cited text no. 24
    
25.
Dumpis U, Balode A, Vigante D, Narbute I, Valenteliene R, Pirags V, et al. Prevalence of nosocomial infections in two Latvian hospitals. Euro Surveill 2003;8:73-8.  Back to cited text no. 25
    
26.
Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infection in US hospitals. Am J Epidemiol 1985;121:182-205.  Back to cited text no. 26
    
27.
Arbi Y, Al-Shirawi N, Memish Z, Anzueto A. Ventilator-associated pneumonia in adults in developing countries; a systematic review. Int J infect Dis 2008;12:505-12.  Back to cited text no. 27
    
28.
Rosenthal VD, Maki DG, Mehta A, Alvarez-Moreno C, Leblebicioglu H, Higuera F, et al. International Nosocomial Infection control consortium report, data summary for 2002-2007, issued January 2008. Am J Infect Control 2008;36:627-37.  Back to cited text no. 28
    
29.
Caplan ES, Hoyt NJ. Identification and treatment of infections in multiply traumatized patients. Am J Med 1985;79 Suppl 1A: S68-76.  Back to cited text no. 29
    
30.
National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System re-port, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470-85.  Back to cited text no. 30
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

This article has been cited by
1 Surveillance systems for health care associated infections
Purva Mathur
Journal of Patient Safety & Infection Control. 2015;
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
 

    

2004 - Indian Journal of Medical Microbiology
Published by Wolters Kluwer - Medknow

Online since April 2001, new site since 1st August '04