Nursing & Health

Surveillance of healthcare-associated infections is central to healthcare epidemiology and infection control programmes and a critical factor in the prevention of these infections. By definition, the term ‘infection prevention’ implies that healthcare-associated infections may be preventable. The purpose of surveillance is to provide quality data that can be used in an effective monitoring and alert system and to reduce the incidence of preventable healthcare-associated infections. This article examines the purpose of surveillance, explains key epidemiological terms, provides an overview of approaches to surveillance and discusses the importance of validation.

Staphylococcus aureus bacteraemia (SAB) is a major cause of morbidity and mortality. During 2009, a national surveillance definition for SAB was developed through the Australian Commission on Safety and Quality in Healthcare (ACSQHC). The aim of this paper is to review the literature surrounding SAB surveillance and in doing so, evaluate the recently developed Australian national definition for SAB. The issues examined in this paper that relate to SAB surveillance include detection, the management of duplicates, classification and acquisition of SAB. Upon reviewing the literature, it was clear that the national Australian SAB surveillance definitions developed by the ACSQHC Healthcare Associated Infection Surveillance Committee are consistent with the majority of literature. Where inconsistencies exist, for example the lack of acquisition information in SAB surveillance programs in the United Kingdom, it is clear that the Australian surveillance definitions are more robust and provide more useful information. The national surveillance definitions for SAB developed by the ACSQHC surveillance committee sets an improved standard for other countries.

Objective To describe the current epidemiology of Clostridium difficile infection (CDI) in Tasmania Design, setting and participants Tasmania undertakes continuous surveillance for CDI at all public hospitals. Data on cases of CDI between 2006 and 2010 were examined. All positive tests occurring within 8 weeks of a previous case, and cases occurring in children less than 2 years old were excluded, consistent with national definitions. Only cases identified at public hospitals were included in the analysis Main outcome measures The rate of CDI in Tasmanian hospitals over the study period and the ability to demonstrate the effect of variances in surveillance definitions. Results A total of 357 cases of CDI were reported over the study period – a rate of 3.08 per 10 000 patient care days (95%CI 2.90–3.27) or 0.94 per 1000 patient separations (95%CI 0.91–0.98) for hospital-identified cases of CDI. Yearly rates for the period 2006 to 2010 were 2.3, 3.2, 2.8 and 3.9 per 10 000 patient care days, respectively. The overall trend was an increase in cases over the study period. The CDI rate from 2009–10 was significantly higher than that from 2008–09. Of the total cases reported,64% were healthcare-associated, healthcare-facility onset (HCAHFO), equating to a rate of 2.1 per 10 000 patient care days over the 4-year period. Conclusion The Tasmanian rate of HCA HFO is increasing, and appears to be greater than that reported by other Australian states, but is less than many northern hemisphere regions, where hypervirulent strains of C. difficile are causing increasing morbidity and mortality. It is difficult to compare reported rates of CDI nationally and internationally owing to inconsistencies in study duration, denominator selection, testing effort and testing methodology. This study demonstrates the need for national standards for CDI testing and reporting.

A point prevalence study was performed to determine the methicillin-resistant Staphylococcus aureus (MRSA) nasal colonisation rates in Tasmanian rural hospital inpatients. Nasal swabs were performed on all Tasmanian rural hospital inpatients hospitalised for more than 48 h before collection. A single swab was collected from both anterior nares and cultured for MRSA. Molecular typing was performed on all MRSA isolated. Demographic and clinical data was collected for each study participant. Data was analysed using the statistical software program SPSS. A total of 185 patients from 14 rural hospitals were included in the study. MRSA was isolated from 13 (7%) patients. Significant differences in MRSA prevalence were found between regions (P < 0.05) and between hospitals (P < 0.05). In the northern region of Tasmania, 11% of rural inpatients were colonised with MRSA, compared with 3 and 0% of rural inpatients in the State’s north-west and

southern regions, respectively. The presence of an indwelling urinary catheter was associated with a higher risk of MRSA nasal colonisation (P = 0.066). Patient age, gender and duration of hospital admission before the swab was collected were not identified as significant risk factors for MRSA nasal colonisation. Twelve of the 13 MRSA (92%) isolated were characterised as ST22-MRSA-IV (EMRSA-15). There is a higher prevalence of MRSA nasal colonisation in rural hospital inpatients in the northern region of Tasmania compared with other Tasmanian regions. ST22-MRSA-IV may be endemic in at least one northern Tasmanian rural hospital. This information may have implications for future strategies designed to minimise the prevalence and transmission of MRSA in Tasmania.

Objective: To report outcomes from the first 2 years of the National Hand Hygiene Initiative (NHHI), a hand hygiene (HH) culture-change program implemented in all Australian hospitals to improve health care workers’ HH compliance, increase use of alcohol-based hand rub and reduce the risk of health care-associated infections.

Design and setting: The HH program was based on the World Health Organization 5 Moments for Hand Hygiene program, and included standardised educational materials and a regular audit system of HH compliance. The NHHI was implemented in January 2009.

Main outcome measures: HH compliance and Staphylococcus aureus bacteraemia (SAB) incidence rates 2 years after NHHI implementation.

Results: In late 2010, the overall national HH compliance rate in 521 hospitals was 68.3% (168 641/246 931 moments), but HH compliance before patient contact was 10%–15% lower than after patient contact. Among sites new to the 5 Moments audit tool, HH compliance improved from 43.6% (6431/14 740) at baseline to 67.8% (106 851/157 708) (P < 0.001). HH compliance was highest among nursing staff (73.6%; 116 851/158 732) and worst among medical staff (52.3%; 17 897/34 224) after 2 years. National incidence rates of methicillin-resistant SAB were stable for the 18 months before the NHHI (July 2007–2008; P = 0.366), but declined after implementation (2009–2010; P = 0.008). Annual national rates of hospital-onset SAB per 10 000 patient-days were 1.004 and 0.995 in 2009 and 2010, respectively, of which about 75% were due to methicillin-susceptible S. aureus.

Conclusions: The NHHI was associated with widespread sustained improvements in HH compliance among Australian health care workers. Although specific linking of SAB rate changes to the NHHI was not possible, further declines in national SAB rates are expected

Objectives: To report the quarterly incidence of hospital-identified Clostridium difficile infection (HI-CDI) in Australia, and to estimate the burden ascribed to hospital-associated (HA) and community-associated (CA) infections.

Design, setting and patients: Prospective surveillance of all cases of CDI diagnosed in hospital patients from 1 January 2011 to 31 December 2012 in 450 public hospitals in all Australian states and the Australian Capital Territory. All patients admitted to inpatient wards or units in acute public hospitals, including psychiatry, rehabilitation and aged care, were included, as well as those attending emergency departments and outpatient clinics.

Main outcome measures: Incidence of HI-CDI (primary outcome); proportion and incidence of HA-CDI and CA-CDI (secondary outcomes).

Results: The annual incidence of HI-CDI increased from 3.25/10 000 patient days (PD) in 2011 to 4.03/10 000 PD in 2012. Poisson regression modelling demonstrated a 29% increase (95% CI, 25% to 34%) per quarter between April and December 2011, with a peak of 4.49/10 000 PD in the October–December quarter. The incidence plateaued in January–March 2012 and then declined by 8% (95% CI, 11% to 5%) per quarter to 3.76/10 000 PD in July–September 2012, after which the rate rose again by 11% (95% CI, 4% to 19%) per quarter to 4.09/10 000 PD in October–December 2012. Trends were similar for HA-CDI and CA-CDI. A subgroup analysis determined that 26% of cases were CA-CDI.

Conclusions: A significant increase in both HA-CDI and CA-CDI identified through hospital surveillance occurred in Australia during 2011–2012. Studies are required to further characterise the epidemiology of CDI in Australia.

Healthcare settings are dangerous places. For those receiving care, the risk of unintended harm from healthcare failures continues to be significant. Given this, there is a need to monitor standards in healthcare, not only to identify potential issues, but also to plan and evaluate interventions aimed at improving healthcare standards. Public reporting of performance standards is one aspect to monitoring standards, but not the only one. Public reporting also brings with it challenges. This perspective explores the recent move to publicly report one healthcare-associated infection (HAI) on the MyHospitals website and comments on the broader issue of using existing HAI data for the purposes of public reporting.

It is encouraging to see the development of new innovations in the area of hospital cleaning.1 However, there remains a fundamental question to answer when evaluating changes in cleaning practice. This question is, “Does a novel cleaning strategy reduce the risk of health care-associated infection and is it a cost-effective use of scarce health care resources?” Lack of evidence on patient outcome remains the single most important deficit when proposing changes to routine cleaning practice. It is also true to say that the role of cleaning itself for controlling health care-associated infection is still hotly debated.