Healthcare Associated Infection...PaGe 2 NSW HealtH Healthcare associated Infection (HaI) Clinical Indicators – Manual Surveillance is an essential component and the only rational

Healthcare Associated Infection:Clinical Indicator Manual

Version 2.0 November 2008

Compiled by: The Quality and Safety Branch

NSW DEPARTMENT OF HEALTH

73 Miller Street

NORTH SYDNEY NSW 2060

Tel. (02) 9391 9000

Fax. (02) 9391 9101

TTY. (02) 9391 9900

NSW Health website www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an

acknowledgement of the source.It may not be reproduced for commercial usage or sale. Reproduction for purposes other than

those indicated above requires written permission from the NSW Department of Health.

© NSW Department of Health 2008

ISBN: 978-1-74187-243-9

SHPN: (QSB) 080136

Further copies of this document can be downloaded from the NSW Health Healthcare-associated infections (HAI) website

http://www.health.nsw.gov.au/quality/hai/

November 2008

NSW HealtH Healthcare associated Infection (HaI) Clinical Indicators – Manual PaGe 1

1 Introduction ....................................................................................................................2

2 Central line associated bloodstream (CLAB) infections in ICU ..................................4

3 Staphylococcus aureus bloodstream infections (SA-BSI).........................................11

4 Surgical site infections (SSI) .......................................................................................17

5 Multi-resistant organisms (MRO) in ICU .....................................................................27

6 References ...................................................................................................................30

7 Appendices ..................................................................................................................31

8 Acknowledgements .....................................................................................................32

Contents

PaGe 2 NSW HealtH Healthcare associated Infection (HaI) Clinical Indicators – Manual

Surveillance is an essential component and the only rational basis of any disease control program. Control of

communicable disease depends on first defining its epidemiology including incidence, risk factors, distribution, and

disease burden. The effectiveness of control programs can only be determined by monitoring changes, from baseline, in

rates of one or more well-defined, objective indicators that can be measured consistently across the target population

and over time.

Healthcare associated infections (HAIs) are varied, complex and difficult to measure. Many are caused by multi-resistant

organisms (MROs) and difficult to treat. They cause significant excess morbidity, mortality and costs and a significant

proportion is preventable. Reductions in HAI rates can be achieved by the effective implementation of “bundles” of

apparently simple preventive measures, including:

■ hand hygiene by healthcare staff before and after touching patients;

■ environmental cleaning;

■ screening of selected patients for colonisation with MROs;

■ contact precautions and/or isolation of patients colonised with MROs or other specified communicable pathogens;

■ appropriate use of antibiotics for surgical prophylaxis and treatment of established infections; and

■ aseptic methods of insertion and care of intravascular devices.

All of these measures are supported by evidence but they are often difficult to implement effectively because of

inadequate resources, education or motivation. Once implemented, compliance varies between facilities, units and

individual clinicians and is difficult to maintain. Measuring the impact of HAIs on patients and healthcare budgets is a

powerful motivator of improvement; monitoring the effects of improvement and feedback of results to health managers

and clinicians is essential to maintain improvement. Equally, demonstrating failure to improve or unsatisfactory levels of

HAI would demand review of and changes to policies and/or implementation methods.

Criteria for choice of specific HAI surveillance indicators include:

■ widely applicable across area health services and public hospitals;

■ easy to measure and meaningful;

■ indicative of serious morbidity and/or mortality and

■ can be reduced by appropriate intervention.

The eight indicators chosen for routine surveillance of HAI in NSW are:

■ Central venous line-associated blood stream infections in intensive care units;

■ Peripherally-inserted central venous line-associated blood stream infections in intensive care units;

■ Staphylococcus aureus blood stream infections;

■ Surgical site infections following hip arthroplasties;

■ Surgical site infections following knee arthroplasties;

■ Surgical site infections following coronary artery bypass graft procedures;

■ Acquisition of methicillin resistant S. aureus (MRSA) in intensive care units and

■ Acquisition of meropenem resistant Acinetorbacter baumannii (MRAB) in intensive care units.

Introduction

SECTION 1


This manual outlines standardised case definitions, denominators and reporting requirements to ensure consistency

across all areas and facilities. Definitions are consistent with those recommended by national and international

authorities. Denominators vary for different indicators; in the near future some (hospital separations or occupied bed

days) will be obtained routinely by NSW Department of Health and others (central-line and ICU bed days; number of

surgical procedures) by each facility.

Results will be collated and analysed by NSW Health Department staff. Individual hospital and aggregate reports will

be generated quarterly and returned to Area Health Services as rapidly as possible for review and action, if required.

Detailed reports will be generated every 6 months.

These indicators are minimum surveillance requirements. They will be reviewed regularly and, if appropriate, changes in

methodology or priorities implemented in response to future trends or feedback from facilities. Additional indicators may

be measured by individual hospitals or units according to local factors and requirements. All indicator rates should be

analysed and reviewed regularly by Area Health Services and facility Infection Control Committees, disseminated to unit

heads and staff with appropriate interpretive comments for action, if necessary.

Table 1: Clinical indicators reported to NSW Department of Health

NSW Department of Health indicators

Mandatory Frequency for reporting to QSB

Requirements for data submission

Central line (centrally and peripherally

inserted) associated bloodstream infections Yes MonthlyWithin 30 days from the end of

the reporting month

Staphylococcus aureus bloodstream

infections Yes Monthly Within 30 days from the end of

the reporting month

Surgical site infections following hip and

knee arthroplasty and coronary artery bypass

grafts

Yes MonthlyWithin 30 days from the end of

the reporting month

Methicillin-resistant Staphylococcus

aureus (MRSA) and meropenem-resistant

Acinetobacter baumanii (MRAB) acquisition

in ICU

Yes MonthlyWithin 30 days from the end of

the reporting month

This manual is to be used in conjunction with the following document:

Area Health Services Care Safe Performance Agreement.


2.1 Rationale

Central line associated bloodstream (CLAB) infections

are responsible for 40-60% of healthcare associated

bloodstream infections (BSI) in intensive care patients.

Risks for occurrence differ among clinical units

depending on the type of line used and site and method

for insertion and post-insertion care.

The majority of CLAB events are preventable through

implementation of prevention and reduction strategies

that are embedded into routine clinical practice

(e.g. practice of the central venous catheter bundle

of care during each insertion). The occurrence of

healthcare-associated BSI can be used as a measure of

the safety of key clinical practice processes. The aim is to

eventually eliminate such events.

Timely investigation of significantly higher than expected

numbers of events or in larger units, rates of infection, may

identify system issues relating to preventative factors.

2.2 Indicator reporting format

CI 1.1 Rate of adult ICU-associated centrally inserted (CI) CLAB infection

Numerator The total number of ICU-associated

CI-CLAB infections for the reporting

month

Denominator The total number of CI-central line

days in ICU for the reporting month

CI 1.2 Rate of Paediatric ICU-associated centrally inserted (CI) CLAB infection


CI-CLAB infections for the reporting

month

Denominator The total number of CI-central line

days in paediatric ICU for the

reporting month

CI 1.3 Rate of adult ICU-associated peripherally-inserted (PI) CLAB infection


PI-CLAB infections for the reporting

month

Denominator The number of PI-central line days

in ICU for the reporting month

CI 1.4 Rate of paediatric ICU-associated peripherally-inserted (PI) CLAB infection


PI-CLAB infections for the reporting

month

Denominator The number of PI-central line

days in paediatric ICU for the

reporting month

2.3 Numerator data

Table 2 provides a guide for the information to assist in

the collection of the numerator. This information is not

required to be reported to NSW Department of Health at

this stage.

Central line associated bloodstream (CLAB)infections in ICU

SECTION 2


Table 2: Numerator data fields for ICU-CLAB

Data field Definition/description Validation requirementHospital name

Patient ID Unique patient identifier

Date of birth Patient date of birth

Lab specimen number Lab number assigned to the specimen

Specimen date Date of first positive blood culture Must not be within 14 days of the commencement

of a previous BSI caused by the same organism(s).

Date must be > 48 hours after ICU admission and

< 48 hours after ICU/HDU discharge.

Type of central line The type of central line associated

with the event that was inserted in the

patient

■ centrally-inserted (CI) central lines

■ peripherally-inserted (PI) central lines

Must not have another diagnosed source of sepsis.

If patient has direct local site evidence of line

infection, ascribe the BSI event to that line. If no

local site infection evidence and multiple

intravascular lines are in place, ascribe the event to

the centrally-inserted line first, thence peripherally-

inserted line in preference to peripheral IV or IA lines.

Site of insertion ■ Subclavian ■ Femoral

■ Jugular ■ Arm

■ Leg

Intensive care type ■ Adult ICU ■ Paediatric ICU If ICU is a combined Paediatric/Adult facility then

specify Adult.

Organism 1 The pathogenic organism isolated from

a blood culture

Organism 2 The second pathogenic organism

isolated from a blood culture

Organism 3 The third pathogenic organism isolated

from a blood culture

2.4 Denominator data

■ An approximation of the number of central line days in ICU (as measured by the tally system, see page 8).

■ ICU has been identified as a high-risk unit for acquiring CLAB.

■ Patients with two or more cental lines in-situ on one day are counted only once i.e. one central line day. If there is a

peripherally and centrally inserted line in situ, count the centrally inserted line only.

2.5 Definition of Terms

2.5.1 Central-line associated bloodstream (CLAB) infection

CLAB infection is defined as a significant BSI with no other apparent focus of infection that occurs in a patient who

either has a central line in place OR who has had a central line removed within 48 hours of the BSI diagnosis.

The National Healthcare Safety Network Definition (http://www.cdc.gov/ncidod/dhap/pdf/nhsn/NHSNManual

PatientSafetyProtocolCURRENT.pdf reproduced in Table 3) is used to determine whether a bloodstream isolate

is significant.

Only intensive care unit-associated infections are reported. These are CLAB infections that are detected > 48 hours

after Intensive care admission and within 48 hours of ICU discharge. Intensive care units that have co-located high

dependency or step down areas should regard these as ICU areas for the purpose of this indicator.


Table 3: Definition of a central-line associated blood stream infection for Adults and Paediatrics

the bloodstream event must meet one of the following three criteria (criteria 1 and 2 may be used for patients

of any age, including patients < 1 year of age):

Criterion 1: Patient has a recognised pathogen cultured

from one or more blood cultures and organism cultured

from blood is not related to an infection at another site.

(See Notes 1 and 2 below.)

Criterion 3: Patient < 1 year of age has at least one of

the following signs or symptoms:

■ fever (>38ºC, rectal);

■ hypothermia (<37ºC, rectal);

■ apnea;

■ or bradycardia

and displays:

■ signs and symptoms of infection and positive

laboratory results are not related to an infection at

another site and common skin contaminant is cultured

from two or more blood cultures drawn on separate

occasions. (See Notes 3, 4 and 5 below.)

Criterion 2: Patient has at least one of the following signs

or symptoms:

■ fever (>38ºC); ■ chills; ■ or hypotension;

and displays:

■ signs and symptoms of infection and positive

laboratory results are not related to an infection at

another site and common skin contaminant is cultured

from two or more blood cultures drawn on separate

occasions. (See Notes 3 and 4 below.)

Notes:

1 In criterion 1, the phrase “one or more blood cultures” means that at least one bottle from a blood draw is

reported by the laboratory as having grown organisms (i.e., is a positive blood culture).

2 In criterion 1, the term “recognised pathogen” does not include organisms considered common skin contaminants

(see criteria 2 and 3 for a list of common skin contaminants). A few of the recognised pathogens are S. aureus,

Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella spp., Candida spp., etc.

3 In criteria 2 and 3, the phrase “two or more blood cultures drawn on separate occasions” means 1) that blood

from at least two blood draws were collected within two days of each other (e.g., blood draws on Monday

and Tuesday or Monday and Wednesday would be acceptable for blood cultures drawn on separate occasions,

but blood draws on Monday and Thursday would be too far apart in time to meet this criterion), and 2) that at

least one bottle from each blood draw is reported by the laboratory as having grown the same common skin

contaminant organism (i.e., is a positive blood culture). (See Note 4 for determining sameness of organisms.)

a For example, an adult patient has blood drawn at 8 a.m. and again at 8:15 a.m. of the same day. Blood from

each blood draw is inoculated into two bottles and incubated (four bottles total). If one bottle from each blood

draw set is positive for coagulase-negative staphylococci, this part of the criterion is met.

b For example, a neonate has blood drawn for culture on Tuesday and again on Saturday and both grow the

same common skin contaminant. Because the time between these blood cultures exceeds the two-day period

for blood draws stipulated in criteria 2 and 3, this part of the criteria is not met.

c A blood culture may consist of a single bottle for a paediatric blood draw due to volume constraints. Therefore,

to meet this part of the criterion, each bottle from two or more draws would have to be culture-positive for the

same skin contaminant.

Examples of common skin contaminants include diphtheroids [Corynebacterium spp.], Bacillus [not B. anthracis]

spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group

streptococci, Aerococcus spp., Micrococcus spp.

4 There are several issues to consider when determining sameness of organisms.

a If the common skin contaminant is identified to the species level from one culture, and a companion culture is

identified with only a descriptive name (i.e., to the genus level), then it is assumed that the organisms are the

same if the antiobiogram is the same. The speciated organism should be reported as the infecting pathogen

(see examples below).


b If common skin contaminant organisms from the cultures are speciated but no antibiograms are done or they

are done for only one of the isolates, it is assumed that the organisms are the same.

c If the common skin contaminants from the cultures have antibiograms that are different for two or more

antimicrobial agents, it is assumed that the organisms are not the same (see table below).

d For the purpose of antibiogram reporting, the category interpretation of intermediate (I) should not be used to

distinguish whether two organisms are different.

Culture Companion Culture Report as… S. epidermidis Coagulase-negative staphylococci S. epidermidis

Bacillus spp. (not anthracis) B. cereus B. cereus

S. salivarius Strep viridans S. salivarius

Organism Name Isolate A Isolate B Interpret as…S. epidermidis All drugs S All drugs S Same

S. epidermidis OX R

ERYTH ROX S (oxacillin)

ERYTH S (erythromycin)

Different

Corynebacterium spp PENG R

CIPRO SPENG S (penicillin G)

CIPRO R (ciprofloxacin)

Different

Strep viridans All drugs S All drugs S except ERYTH (R) Same

Notes:

5 For patients < 1 year of age, the following temperature equivalents for fever and hypothermia may be used: Fever:

38°C rectal/tympanic/temporal artery = 37°C oral = 36°C axillary Hypothermia: 37°C rectal/tympanic/temporal

artery = 36°C oral = 35°C axillary.

2.5.2 Central lines

Central lines are classified as intravascular devices with a tip ending in a major vein (includes subclavian vein). Central

lines are classified as either ‘centrally inserted’ in which case the skin entry point is on the trunk of the patient or

‘peripherally-inserted’ where the line inserted through a limb vein.

These KPI definitions stratify infections by insertion site (central or peripheral) in view of the significant differences

between infection rates related to these line types. Within the category of centrally-inserted lines, there are also variation

in infection rates according to type of line and site of insertion. It is advisable for units to routinely record the site of

insertion and type of line in order to investigate unexpected changes in infection rates that may relate to these variables

(e.g. over-reliance on jugular or femoral central lines which usually exhibit higher CLAB rates).

2.5.3 Central line days

Central line days is the count of the number of patients with a central line in situ on each day stratified by CI central

lines and PI central lines. Only one central line day is attributed to each patient regardless of the number of lines. Where

a patient has both a centrally-inserted central line and a peripherally-inserted central line, the centrally-inserted central

line is the only line that is counted. (Refer to 2.6.1 Method for collecting denominator data for central line days).

2.5.4 ICU

ICU includes adult and paediatric ICU

An ICU includes an ICU, CICU, CCU and HDU. Refer to Intensive Care Coordinating and Monitoring Unit website at

http://intensivecare.hsnet.nsw.gov.au/five/htm/definitions.php

Only include those NSW healthcare facilities that are listed at this site http://intensivecare.hsnet.nsw.gov.au/five/htm/

locations.php


2.6 Surveillance methodology

2.6.1 Method for collecting denominator data for central line days

Denominator data should be collected by the tally

method. This involves estimating the total central line

days per month based on daily averages calculated from

counting patients with central lines on 3-5 days per

week. One line per patient is counted only.

Procedure for using the tally system

■ Record the number of patients in ICU that have a

centrally inserted (CI) central line in-situ at approximately

the same time on each of the 3-5 days per week.

Tally on the last day of the month to obtain the

number of CI central line days for that month.

■ Record the number of patients in ICU that have

a peripherally inserted (PI) central line in-situ at

approximately the same time on each of the 3-5 days

per week. Tally on the last day of the month to obtain

the number of PI central line days for that month.

■ When calculating centrally inserted (CI) central line

days all types of CI central lines (cuffed and non-

cuffed, implanted etc) in-situ during the time period

under study are included. Patients with two CI

central lines in place on the one day are counted as

one CI central line.

■ When calculating peripherally inserted (PI) central line

days all types of PI central lines are counted. Patients

with two PI central lines in place on the one day are

counted as one PI central line.

■ If there is a peripherally and centrally inserted line in situ

on the same patient, count the centrally inserted line only.

For guidance about collection of patient line-

day denominators, consult: http://www.asid.net.

au/hicsigwiki/index.php?title=Central_line_day_

denominator_counting_methods

Calculate the number of catheter line days as follows:

Centrally-inserted central line days =

The total number of patients with centrally-inserted lines

counted x number of days in the month divided by the

total number of days in which centrally-inserted lines

were counted.

Peripherally-inserted central line days =

The total number of patients with peripherally-inserted

lines counted x number of days in the month divided by

the total number of days in which peripherally-inserted

lines were counted.

Table 4: ICU tally tool

Central line days – ICU tally toolMonth: Year:Day of month Total number of

CI central lines

PI central lines

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Total number of central lines a a

Number of days counted in

the month

b b

Average number of central

lines per day

c=(a/b) c=(a/b)

Number of days in the month d d

Total central line days for month

e=c x d e=c x d

see Central Line Days Tally Tool -> click to view / download

http://www.health.nsw.gov.au/quality/hai/docs/tally_tool.xls


Table 5: ICU tally tool – worked example

Central line days – ICU tally toolMonth: July Year: 2007Day of month Total number of

CI central lines

PI central lines

1 20 5

2 15 4

3 22 5

4

5

6

7

8 24 3

9 24 4

10 25 3

11

12

13

14

15 20 4

16 18 4

17 22 4

18

19

20

21

22 25 3

23 25 3

24 22 3

25

26

27

28

29 24 3

30 22 3

31 20 3

Total number of central lines 328 54

Number of days counted in

the month

15 15

Average number of central

lines per day

21.9 3.6

Number of days in the month 31 31

Total central line days for month

678 112

2.6.2 Requirements for optimal detection of bloodstream infections

■ Minimum of two sets are to be collected from each

patient. The two sets should be collected from

different peripheral veins. In an adult, 10ml of blood

is required for each bottle of the set. Usual volume of

a single paediatric bottle is 1-3mLs.

■ Do not collect cultures via an existing central

venous catheter or peripheral line - potential for

contamination from hub and/or infection of line.

Exception is immediately after insertion.

■ The collection technique is important in order

to avoid contamination and ensure sensitivity.

The collector should attend hand hygiene and put

on personal protective equipment (eyewear and

sterile gloves)

skin disinfection with alcohol (wet site well with

circular action around planned venipuncture site,

allow 1-2 minutes for antiseptic action to complete)

ensure top of blood culture bottle is adequately

disinfected – alcohol, 1-2 minutes exposure time

(do this prior to venipuncture)

no-touch needle insertion for venipuncture

DO NOT change needle prior to inoculation

(risk of injury)

DO NOT overfill bottles (renders culture

less sensitive)

2.6.3 Detection of central line-associated infection

■ Ensure appropriate blood culture collection (above)

when indicated and ensure appropriate checking

of results to detect central line-associated infections.

■ Examine and document central line exit sites daily for

exudate and/or inflammation.

■ If line sepsis suspected, submit aseptically collected

line tip for semi-quantitative culture in addition to

two blood culture sets if patient is febrile.

Note: Culture of line tips in asymptomatic patients is

NOT recommended.

2.6.4 Method for identifying central line-associated events in the hospital

■ Determine whether bloodstream infection

has occurred

■ Determine whether this is a new event (not a repeat

isolate within 14 days)see Worked Example Central Line days – ICU tally tool -> click to view / download

see Central Line Days Tally Tool -> click to view / download

http://www.health.nsw.gov.au/quality/hai/docs/worked_example_tally_tool.xls


■ Determine whether the CLAB event was ICU-associated

by checking whether the patient was admitted to ICU

and the dates of the ICU admission. ICU-associated

events occur > 48 hours after ICU admission and within

48 hours of ICU discharge.

Note: where a patient has a peripheral IV or arterial

cannula(e) in addition to a central line(s), the central line

becomes associated with the blood event, unless there

is direct evidence of local sepsis at the peripheral or

arterial site.

2.7 Surveillance validation

Nominated microbiologist, infectious diseases physician

and/or Infection Control Professional should audit

reported numerator events prior to submission of the

monthly report to NSW Department of Health. Each

event should be fully investigated at the time.

2.8 Calculations of CLAB

CLAB rate is expressed per 1,000 line days

CLAB rate =

Number of BSI in patients with central lines x 1,000

Number of central line days

2.9 Reporting requirements

2.9.1 Instructions for submitting data to NSW Department of Health

Enter data into the NSW Department of Health HAI

database within 30 days of the close of the reporting

period e.g. March data is due by 30 April.

Each ICU also has to submit central line insertion audit

sheets to the Clinical Excellence Commission.

2.10 Reports from NSW Department of Health

Reports provided by NSW Department of Health

to the AHS:

■ Monthly counts

■ Rate per 1,000 patient line days of centrally

and peripherally inserted central venous lines in ICU.

Analysis:

■ Monthly aggregate mean CLAB rate

■ Monthly mean insertion compliance rate

Benchmarks:

■ VICNISS (Victorian Nosocomial Infection

Surveillance System)

■ HISWA (Healthcare Infection Surveillance

Western Australia)


Staphylococcus aureus bloodstream infections (SA-BSI)

SECTION 3

3.1 Rationale

Staphylococcus aureus, a bacterium that commonly

colonises human skin and mucosa, is amongst the

commonest and most serious causes of community and

healthcare associated sepsis. Staphylococcus aureus

bloodstream infections (SA-BSI) are associated with

substantial morbidity and mortality worldwide. SA-BSI

impacts on resources (both human and financial). There

is emerging evidence that many healthcare/associated

methicillin susceptible S. aureus (MSSA) and methicillin

resistant S. aureus (MRSA) are preventable through

better infection prevention and control.

Incidence of healthcare associated SA-BSI is used as

an outcome indicator for hand hygiene compliance of

healthcare workers.

3.2 Indicator reporting requirements Each Area Health Service is to report individual

significant SA-BSI events monthly. The necessary report

format is specified under Section 3.3 Numerator data.

Event data will be categorised into six categories by NSW

Health. These include:

CI 2.1 Healthcare associated (inpatient) methicillin sensitive Staphylococcus aureus bloodstream infections – (HCA (inpatient) MSSA BSI).

CI 2.2 Healthcare associated (inpatient) methicillin resistant Staphylococcus aureus bloodstream infections – (HCA (inpatient) MRSA BSI).

CI 2.3 Healthcare associated (non-inpatient) methicillin sensitive Staphylococcus aureus bloodstream infections – (HCA (non-inpatient) MSSA BSI).

CI 2.4 Healthcare associated (non-inpatient) methicillin resistant Staphylococcus aureus bloodstream infections – (HCA (non-inpatient) MRSA BSI).

CI 2.5 Community associated methicillin sensitive Staphylococcus aureus bloodstream infections - (Community-associated MSSA BSI).

CI 2.6 Community associated methicillin resistant Staphylococcus aureus bloodstream infections - (Community-associated MRSA BSI).

The first four event types will be put against total

separations and total occupied bed-days for each facility

to express rates per 100 separations and per 1000

occupied bed days.

The community associated events will be expressed as

numerators alone.

3.3 Numerator data

3.3.1 Inclusions

All bloodstream infections caused by Staphylococcus

aureus:

■ MSSA

■ MRSA (all strains).

3.3.2 Exclusions

There should be no exclusions except for rare occasions,

isolation of MSSA or MRSA from blood can represent

blood culture contamination. If contamination is

suspected, detailed clinical evaluation and repeat blood

cultures off antibiotics are necessary in order to confirm

this. Events that are determined not to be significant are

not reported.


Table 6 provides a guide for the information to assist in the collection of the numerator. This information is not required

to be reported to NSW Department of Health at this stage.

Table 6: Numerator data fields for specific organism BSI

Data field Definition/description ValidationFacility/hospital Name of facility / hospital where patient

presented or was being managed.

For non-inpatient HCA events that derive from

admission or procedure associated with another

facility/hospital, specify the full name of that facility.



Patient postcode Postcode of patient's home address

Lab specimen number Lab number assigned to the specimen

Specimen date Date the specimen was obtained Should be date of first positive blood culture isolate.

Must not be within 14 days of the commencement

of a previous BSI caused by the same organism(s).

Organism Significant organism isolated

■ MSSA

■ MRSA

Acquisition Place of probable acquisition of the

bloodstream infection

■ Inpatient

■ Non-inpatient

■ Community-associated

Refer to the definition below for HCA non-

inpatient definitions.

Inpatient events MUST have occurred > 48 hours

after admission and within 48 hours of hospital

discharge.

Report maternally-acquired events as

community-associated

Focus of infection The likely source/cause of the BSI

■ IV line related

■ Procedure related

■ Non-IV device related

■ Other (organ site focus)

■ Unknown / disseminated

See below


NSW Health will access total separations and total occupied bed-days for each facility.


3.5 Definition of terms3.5.1 Staphylococcus aureus bloodstream

infection

Isolation of Staphylococcus aureus from one or more

blood cultures.

Note: Staphylococcus aureus is an uncommon blood

culture contaminant and therefore false positives are

unlikely.

Beta-lactam antibiotics include penicillins and

cephalosporins. The only ones commonly used to treat

S. aureus infections are flucloxacillin and dicloxacillin

and the first generation cephalosporins and the closely

related carbapenems have reasonable antistaphylococcal

activity. So-called methicillin resistance in S. aureus is due

to the production of an altered penicillin binding protein

which allows the bacteria to bypass the bactericidal

action of all beta-lactams. Thus MRSA is resistant to all

drugs in this class as well as carbapenems. Methicillin,

oxacillin or cefoxitin are used in the laboratory to test

the susceptibility of S. aureus to these agents.

Note: A bloodstream infection due to the same

organism that recurs within 14 days of the original event

is disregarded and not counted as a new event as it is

considered to be the same infection. If antimicrobials

are given for less than 14 days for dialysis access

line¬associated infection and then restarted for the same

infection, this is NOT considered a new event. However,

if IV antimicrobials are stopped for 14 days or more and

then restarted for a BSI with the same organism, this is

considered a new event.

Note: *Neutropenia sepsis – BSI definition

Defined as a BSI occurring in a patient with a neutrophil

count less than 1 × 109 /L (1000/mm3). Because the

majority of these patients have an indwelling central

line, and no clinically apparent focus of infection, the

source is usually attributed as line associated sepsis.

This potentially leads to a high number of false positive

categorisations of line associated sepsis in this group.

The source in this group is usually unknown, but

thought to be the mucositis caused by chemotherapeutic

drugs. A positive catheter tip culture with the same

organism as the blood culture is strong evidence that

a central line is the source of the BSI. Neutropaenic

patients with clinical mucositis and no other clinical

focus should have the infection source designated as –

organ site focus – gastrointestinal.

3.5.2 Healthcare associated bloodstream infection

Healthcare associated BSI events are further classified as:

■ Inpatient – acquired during hospitalisation – event

detected > 48 hours after hospital admission and/or

within 48 hours of hospital discharge

■ Non-inpatient – Not acquired during inpatient

hospital admission (48 hour rule), but meets at least

one other criteria for healthcare associated BSI as

described in Table 7.

Healthcare associated BSI must satisfy at least one of the criteria listed below:A bloodstream infection occurring in a patient

from the community or within 48 hrs of admission

is deemed to be healthcare-associated if one of

the following criteria are satisfied:

1. Is a complication of the presence of an

indwelling medical device (e.g. IV catheter, urinary

catheter) (no other primary focus of infection

diagnosed).

2. Occurred within thirty days of a surgical

procedure, where the bloodstream infection is

related to the Surgical Site Infection.

3. An invasive instrumentation or incision related

to the bloodstream infection was performed within

48 hours before onset of the infection. If the time

interval was longer than 48 hours, there must be

compelling evidence that the infection was related

to the invasive device or procedure.

4. Was associated with neutropenia (<1000

neutrophils x 106/L) contributed to by cytotoxic

therapy.

Table 7: Healthcare associated BSI

Note: The following are NOT classified as healthcare

associated BSI:

Community acquired: Manifest within 48 hours after

admission and not healthcare associated.

Maternally–acquired: Infection in a neonate that is

acquired from the mother during delivery. Unless strong

evidence suggests otherwise, an infection that appears

less than 48 hours after birth is considered to be

acquired from the mother.


Figure 1. S aureus BSI classification flowchart

Laboratory report – S.aureus

isolated from blood culture

YES

NO

Determine likely source of BSI First identify any organ site focus of infection

■ procedure related

■ non-IV device related

■ other (organ site focus)

OR neutropenia sepsis

Validation See definition for

focus of infection

(see 3.5.3)

Classify as unknownNO

Meets criteria for Healthcare-associated SA-BSI

Is the BSI healthcare associated?

Inpatient?

YES

Classify as MSSA or MRSA


S.aureus BSI

(see 3.5.1)

YES


healthcare associated

infection: Inpatient

(48 hour rule)

or

non-inpatient health

care associated

(see 3.5.2)

Classify as

community

associated Community-associated

NO

YESValidation

See definition for

focus of infection

(see 3.5.3)

Classify as IV related

Determine likely source of BSI Step 1 – ? IV related.

Was the IV line in-situ within 48 hours of BSI

event and there was no other S.aureus

focus of infection as the likely

cause of BSI


3.5.3 Focus of infection (likely source of infection)

Table 8: Focus of infection

IV line related BSIs This requires an intravascular

catheter to be present within 48 hours of the date

that the positive blood culture was obtained or within

48 hours of commencement of signs and symptoms

of infection indicating that the BSI was incubating

and there are no other S. aureus organ site focus of

infection present that are likely to have caused the BSI.

Procedure related BSIs This requires clinical and

bacteriological evidence that the BSI arose from

infection at a specific organ site that can be related

to a surgical procedure within the last 30 days* or

that the BSI arose from infection at a specific organ

site that can be related to an invasive medical or

anaesthetic procedure within previous 48 hours*.

Non-IV device related BSI There is compelling

clinical or microbiological evidence that the BSI arose

from an organ site focus of infection at the site of a

non–IV device that was present within 48 hours* of

the BSI event. e.g. shunt, supra–pubic catheter; chest

tube.

Other (organ site focus of infection) There is

clinical and bacteriological evidence that the BSI

developed as a result of infection at a specific organ

site and is not related to a procedure or non–IV device

e.g. urinary tract, respiratory tract, gastrointestinal,

bone and joint, skin and soft tissue, head & neck,

cardiovascular, genital tract, central nervous system,

hepatobiliary

Criteria for diagnosis of infection at specific organ site

are defined by CDC: http://www.cdc.gov/ncidod/dhqp/

pdf/nnis/NosInfDefinitions.pdf

Unknown or disseminated The source of the BSI

cannot be determined or there are multiple organ site

foci of S. aureus infection.

Neutropenia sepsis Defined as a BSI occurring in a

patient with a neutrophil count less than 1 × 109 /L

(1000/mm3). Because the majority of these patients

have an indwelling central line, and no clinically

apparent focus of infection neutropænic patients will

be classified as either:

■ IV related – evidence required e.g. catheter tip

culture with S. aureus or exit site infection

■ Other (organ site focus) – if mucositis or another S.

aureus organ site focus is present

■ Unknown

* If the time interval was longer, there must be

compelling evidence that the BSI was related to the

procedure.


3.6.1 Method for collecting numerator data

The value of surveillance is enhanced by providing high

quality comparative data. For participating hospitals to

make a valid comparison of the MRSA infection rates

the methodology used must be similar and definitions

consistently applied. Therefore active, prospective,

patient-based surveillance is required as outlined.

active, prospective, patient based surveillance

■ Processes should be in place for laboratory systems

servicing each hospital to notify infection control

staff directly of all positive S. aureus blood cultures

in real-time. Close liaison with the microbiology

laboratory is essential.

■ Trained infection prevention control staff should have

the key role of classification as per definitions.

■ Clinical liaison is essential for classification of many

BSI events, and involvement of clinical microbiologist

/ infectious diseases physicians/treating clinician

and infection prevention and control staff will be

important.

■ Other validation requirements outlined generally

include:

Review of medical records and medication charts

Review of patient management systems/

administrative data to determine admission

information


Regular audit of reports against laboratory data to assess:

■ Completeness of notification (examine all laboratory

detections of S. aureus in blood)

■ Correct assignment of healthcare associated status

(examine all unique S. aureus events)

■ Correct assignment of organism phenotype

(examine reported phenotypes and compare with

laboratory reports)

■ Ensure new MRSA BSI isolates are referred for

genotyping to the relevant reference laboratory.


3.8 Calculation of SA-BSI

SA-BSI rate can be expressed per 100 separations

SA-BSI rate = Number of patients with SA-BSI x 100

Number of separations

and




Database within 30 days of the close of the reporting

period (eg. March data is due by 30th April).


HCA BSI rates will be reported against separations

and occupied bed days for MRSA and MSSA separately.

CA BSI events reported as numbers only.

Numerators and denominators for each facility will be

reported through to Hand Hygiene Australia.

Analysis:

■ Monthly mean SA-BSI rates by hospital/facility

Benchmark:

■ NSW Health also reports forward to Hand Hygiene

Australia the healthcare - associated SA_BSI figures.

SA-BSI rate = Number of patients with SA-BSI x 1,000

Number of occupied bed days


4.1 Rationale

Proper surgical process control (peri-operative,

operative and postoperative care) is associated with

very low infection rates in clean surgical procedures.

Measurement of SSI outcomes is indicated to detect

potential failures of process control that require

investigation to determine cause(s) and necessary

corrective action(s).


CI 3.1 Rate of superficial incisional SSI following hip arthroplasty

Numerator The total number of superficial

incisional surgical site infections

in hip arthroplasty procedures in

reporting month

Denominator The number of hip arthroplasty

procedures performed in reporting

month

CI 3.2 Rate of deep incisional/organ space SSI following hip arthroplasty

Numerator The total number of deep incisional/

organ space surgical site infections in

hip arthroplasty procedures in reporting

month

Denominator The number of hip arthroplasty


month

CI 3.3 Rate of superficial incisional SSI following knee arthroplasty


incisional surgical site infections

in knee arthroplasty procedures in

reporting month

Denominator The number of knee arthroplasty


month

CI 3.4 Rate of deep incisional/organ space SSI following knee arthroplasty

Numerator The total number of deep/organ

space surgical site infections in knee

arthroplasty procedures in reporting

month

Denominator The number of knee arthroplasty


month

CI 3.5 Rate of superficial incisional sternal site SSI following coronary artery bypass grafts (CABG)


incisional sternal site SSI in CABG

procedures in reporting month

Denominator The total number of CABG procedures

performed in reporting month

CI 3.6 Rate of deep incisional sternal site/organ space SSI following coronary artery bypass grafts (CABG)

Numerator The total number of deep incisional

sternal site/organ space SSI in CABG

procedures in the reporting month

Denominator The total number of CABG procedures

performed in reporting month.

Surgical Site Infections (SSI)

SECTION 4


4.3 Numerator data

Table 9 provides a guide for the information to assist in the collection of the numerator. This information is not required

to be reported to NSW Department of Health at this stage.

Table 9: Numerator data fields for SSI

Data field Definition / DescriptionFacility/hospital



Procedure Inclusions: all elective arthroplasty procedures - includes total, revision, partial. Sub categories:

primary and revision

Date of procedure Date the operative procedure was performed

Date infection

identified

Date the infection was identified

NNIS (NHSN)

Risk Index

Patient risk index classified as 0, 1, 2, 3, n/a. ‘n/a’ = risk index not available

Point of detection Point of detection.

■ Initial admission

■ Readmission

■ Outpatient or other post discharge

Infection classification The anatomical classification of the type of infection.

■ Superficial

■ Deep/organ space.

Specimen Classification of the specimen:

■ Sterile

■ Non-sterile

■ Not obtained

Organism 1 The pathogenic organism isolated from a specimen (if detected)

Organism 2 The second pathogenic organism isolated from a specimen (if detected)

Organism 3 The third pathogenic organism isolated from a specimen (if detected)

4.3.1 Exclusions

Hip and knee arthroplasty procedures:

■ SSI from emergency procedures eg. hemiarthroplasty of fractured neck of femur

■ SSI detected > 1 year from date of procedure

■ Superficial SSI that are detected more than 30 days after the procedure

Coronary artery bypass grafts (CABG) procedures:

■ Graft donor sites



Hip and knee arthroplasty procedures

■ The total number of elective hip and knee

arthroplasty procedures including total, revision

and partial.

■ Bilateral procedures are counted as one operation.

■ All revision procedures, including those for

mechanical and infective reasons, will be counted

in the denominator.

Coronary artery bypass grafts (CABG)

■ The total number of elective CABG

4.4.1 Exclusions

■ Emergency and unplanned hip and knee arthroplasty

procedures

■ Emergency and unplanned CABG

4.5 Definition of terms

4.5.1 Superficial/deep incisional/organ space

■ A superficial SSI is defined as an infection that

involves only the skin and subcutaneous tissue of the

incision.

■ A deep incisional/organ space SSI is defined as

infection involving deep soft tissues e.g. fascial

and muscle layers and/or organs/spaces opened or

manipulated during an operation. A more detailed

definition is provided in Table 10.

Figure 2 Schematic of surgical site infection (SSI) anatomy and appropriate classification (Horan et al. 1992)

Skin {{{{

Subcutaneous tissue

Deep soft tissue (fascia and muscle)

Organ/space

Superficial incisional SSI

Deep incisional SSI

Organ/space SSI


Table 10: Definition for superficial and deep surgical site infections

SUPeRFICIal INCISIONal DeeP INCISIONal/ORGaN SPaCe

Definition must meet the following criteria: Definition must meet the following criteria:

Infection involves only skin and subcutaneous tissue of this

incision

and

occurs within 30 days after the operative procedure

and

exhibits at least one of the following from the superficial

incision:

1. Purulent discharge (not stitch abscess).

2. Organisms isolated from an aseptically collected culture

of fluid or tissue.

Note: A positive wound swab (in contrast to wound

aspirate) without other significant evidence of infection is

not adequate for diagnosis of infection.

3. Displays, at the site of incision, any of the following

signs and symptoms of infection:

■ Pain or tenderness

■ Localised swelling

■ Redness or heat

and

the incision is deliberately explored by the surgeon

resulting in a positive wound culture. Note: A culture-

negative finding does not meet this criterion unless the

patient was on antibiotics immediately prior to diagnosis.

4. Diagnosis or antimicrobial treatment of superficial

incisional infection by the operating surgeon or

registrar.

Infection involves deep soft tissues (e.g. fascial and

muscle layers)

and/or

organs/spaces opened or manipulated during an operation

and

occurs within 30 days after the operative procedure if

implant not present OR within one year if implant in situ

and

exhibits either one or both of the following:

1. Purulent drainage from deep soft tissue or drain that is

placed through a stab wound into the organ/space.

2. Spontaneous dehiscence at the incision site or the

wound is deliberately explored by a surgeon with

the patient showing evidence of one or more of the

following signs or symptoms:

■ Fever > 38ºC, localised pain or tenderness with culture-

positive specimen. A culture-negative finding does not

meet this criterion unless the patient was on antibiotics

immediately prior to the wound being explored and/or

the culture being taken.

■ Organisms isolated from aseptically obtained culture of

fluid or tissue obtained from an organ/space.

■ An abscess or other evidence of infection involving

a deep/organ space is found on direct examination,

during reoperation, or by histopathologic or radiologic

examination.

■ Diagnosis of or antimicrobial treatment of a deep

incisional or organ/space SSI by the operating surgeon

or registrar


Table 11: Reporting instructions for superficial and deep surgical site infections

SUPeRFICIal INCISIONal DeeP INCISIONal/ORGaN SPaCe

Reporting instructions Reporting instructions

1. Do not report a stitch abscess (minimal inflammation

and discharge confined to the points of suture

penetration) as an infection.

2. If infection involves or extends into fascial and muscle

layers, report as deep/organ space SSI.

1. Classify infection that involves both superficial and deep

incisional sites as deep incisional SSI.

2. The following are examples of specific sites of an organ/

space SSI, relevant to joint replacement and coronary

artery bypass graft surgery:

■ Osteomyelitis

■ Myocarditis or pericarditis

■ Joint or bursa infections

■ Mediastinitis

■ Arterial or venous infection

4.5.2 Specimen classification

Sterile specimen

■ aspirate collected aseptically

■ specimen collected in theatre

■ swab of tissue in theatre

Non-sterile specimen

■ swab of wound

■ expressed or dehisced wound fluid

4.5.3 Point of detection of SSI

Infections may be detected at three possible points and recorded as follows:

1. Detected during admission: During the period that the patient is hospitalised following the procedure and prior to

discharge.

2. Detected on readmission to hospital for treatment of SSI: Readmitted for treatment of SSI within 30 days (superficial

SSI) and within 1 year of procedure (deep/organ space) e.g. antibiotic treatment, surgical site washouts, removal of

prosthesis etc. ICD-10-AM codes may assist data collection of readmissions.

3. Detected while treated as an outpatient or other post-discharge methods and is not admitted to hospital for

treatment (treated entirely as an outpatient): e.g. Outpatient Clinics, GP notification, HITH (hospital in the home),

active post-discharge surveillance e.g. letters, telephone calls etc. However, due to the lack of post-discharge

surveillance uniformity between institutions, these data will not be included in monthly reports.


4.5.4 Risk index calculation

The risk index is recommended by National Hospital Safety

Network (USA, formally the National Nosocomial Infection

Surveillance system (NNIS)) as a method of stratification of

risk for infection for surgical site infections. The higher the

patient’s risk index the higher the risk of SSI. Risk

adjusted rates allows statistical adjustment for differences

across participating hospitals. The risk index consists of

three host related and operation related risk factors and

scores are allocated as indicated (see Table 12).

Risk index score = ASA score + Length of surgery score +

Wound class score

Note:

Primary arthroplasty procedures will have a wound

classification of ‘clean’ and the wound class score will

be 0. If there is a major break in sterile technique during

the surgery the wound classification is ‘contaminated’

and the wound class score will be 1.

Revision arthroplasty procedures for mechanical reasons

will have a wound classification of ‘clean’ and the

wound class score will be 0. If there is a major break

in sterile technique during the surgery the wound

classification is ‘contaminated’ and the wound class

score will be 1.

Revision arthroplasty for infective reasons will have a

wound classification of ‘dirty infected’ and the wound

class score will be 1.


Table 12: Calculation of risk index score

1. ASA

The ASA physical status classification system refers to the American Society of Anaesthesiology class and is a

numerical quantification of disease severity in patients undergoing general anaesthesia. This classification is a relatively

standardised scoring scheme developed to stratify anaesthesia risk. Studies have demonstrated that ASA class is a

useful indicator of host susceptibility to infection for epidemiological purposes. A score of 0 can be entered when the

ASA score cannot be established.

ASA class Description Risk index score

1 A normal healthy patient 0

2 A patient with mild systemic disease 0

3 A patient with severe systemic disease 1

4 A patient with severe systemic disease that is a constant threat to life 1

5 A moribund patient who is not expected to survive without the operation 1

2. Length of surgery > than expectedThe NNIS duration of surgery data, lists duration cut points for surgical procedures which approximate the 75th

percentile of the duration of surgery (NNIS 2004). Thus if a procedure is longer than the reported duration cut point

then 1 risk point is scored.

Procedure Duration cut point Risk index score

Hip/knee arthroplasty < 2 hours 0

Hip/knee arthroplasty > 2 hours 1

Coronary artery

bypass grafts

< 5 hours 0

Coronary artery

bypass grafts

> 5 hours 1

3. Wound class Surgical Wound classification

Description Risk index score

Clean An infected operative wound in which no inflammation is encountered and

the respiratory, alimentary, genital, or uninfected urinary tract is not entered.

In addition, clean wounds are primarily closed and, if necessary, drained with

closed drainage. Operative incisional wounds that follow non-penetrating

(blunt) trauma should be included in this category if they meet the criteria.

0

Clean-contaminated An operative wound in which the respiratory, alimentary, genital, or

urinary tract are entered under controlled conditions and without unusual

contamination. Specifically, operations involving the biliary tract, appendix,

vagina, and oropharynx are included in this category, provided no evidence of

infection or major breaks in technique is encountered

0

Contaminated Open, fresh, accidental wounds. In addition, operations with major breaks

in sterile technique (eg. Open cardiac massage) or gross spillage from the

gastrointestinal tract, and incisions in which acute, non-purulent inflammation

is encountered are included in this category.

1

Dirty infected Old traumatic wounds with retained devitalized tissue and those that involve

existing clinical infection or perforated viscera. This definition suggests that the

organisms causing postoperative infection were present in the operative field

before the operation

1



Standardised and consistent methods for the collection,

detection and reporting of SSI data is required to ensure

that the data reported is meaningful to healthcare

workers to identify strategies for infection reduction.

The most reliable method is active, prospective, patient-

based surveillance which is a combination of the

following activities outlined.

4.6.1 Active, prospective, case-finding

Key points:

■ Active processes should be developed to detect SSI

from the time of the surgical procedure and during

the post-operative stay until discharge.

■ A combination of several case-finding methods

should be in place that does not rely entirely on

reviewing laboratory results or passive information

from clinical staff.

■ Microbiology results should be interpreted in

conjunction with the information from clinical

sources.

■ Processes should also be developed to detect patients

who are readmitted to hospital for treatment of deep

SSI up to 1 year after a prosthetic joint procedure.

Case-finding surveillance activities:

■ Regular ward rounds – visit patients following

surgery, liaise with ward and clinical staff

■ Total chart review – medical records, medication

charts for antibiotics, wound management plans,

temp chart etc

■ Sentinel forms – i.e. notification by clinical staff

■ Laboratory reports for eligible patients

■ Pharmacy dispensing records

■ Review of referrals for Microbiologist / Infectious

Diseases Physician consults

■ Examine coding of hospital admissions and

re-admissions to detect unsuspected infections.

4.6.2 Classification of SSI

In order to improve consistency and validity of data

infection control professionals should:

■ Classify SSI strictly according to definition

■ Explain the classification of the SSI to the surgical

team

■ Network with other clinical experts/microbiologists

for difficult classifications

4.6.3 Patient–based surveillance

Key Points:

■ Patient-based surveillance requires identification of

all eligible patients for inclusion in the surveillance

(denominator) and follow-up of SSI outcomes.

■ Eligible patients are all patients undergoing elective

hip and knee arthroplasty procedures (including total,

revision, and partial operations) and CABG.

Eligible patients can be determined in liaison with:

■ Theatre management systems

■ Theatre booking slips

■ Medical records systems and notifications from

theatre staff (smaller hospitals)

■ Theatre coding

4.6.4 Period of follow-up

■ All eligible patients should be actively followed-up

during the initial admission period i.e. from the time

of the procedure until discharge.

■ Due to the insertion of an implant, eligible patients

require follow-up for up to 1 year following the

procedure i.e. readmissions to hospital for treatment.

■ Positive, deep organ space infections recognised >30

days are reported to NSW Department of Health in

the month it is identified.


4.6.5 Detection of SSI

All hospitals are required to submit data for SSI detected:

■ During the initial admission period following the

procedure (superficial SSI < 30 days)

■ On readmission to hospital for treatment -

If a SSI is detected at a hospital other than that

performing the initial surgery, the original hospital

should be informed and the SSI recorded with

that hospital’s data.

It is not mandatory for hospitals to conduct or report

additional post-discharge surveillance that identifies

SSI that are treated completely outside the hospital

e.g. outpatients. However, NSW Department of Health

encourages local reporting of post-discharge surveillance

activities, but SSI identified from these methods will not

be included in reports e.g. GP notifications, outpatient

clinics etc.

4.6.6 Risk Index

There are many extrinsic and intrinsic risk factors that

increase the likelihood of a surgical patient acquiring an

infection.

It is recommended that hospitals performing hip and

knee arthroplasty and CABG calculate the risk index for

all eligible patients to enable risk analysis/adjustment in

the event of significant changes in infection rates over

time.

Refer to 4.5.4 Risk index calculation.


■ Hospitals should periodically review and validate

their internal processes to ensure they are effectively

collecting the required data, preferably by an

independent audit.

■ Ensure that cases are classified correctly as to deep/

organ versus superficial site.

■ In the event of a rise in infection rates, all SSI events

need to be re-examined to check that they satisfy the

SSI definition.

■ Examine other case finding methods to look for

missed cases (eg. Letters to consultants, recheck of

readmission records, admissions to home intravenous

antibiotic programs, infectious diseases consultation

records).

■ Liaise with expert clinical staff, microbiologists and

clinical governance units.

■ Monitor readmissions, re-operations and admissions

to home intravenous programs to detect cases.

4.8 Calculation of SSI

The rate of surgical site infections for each of the

indicators is expressed per 100 procedures and is

calculated and reported separately, stratified by the

NHSN risk index (0,1,2,3)

SSI = Number of infections x 100

Number of procedures


4.9.1 Instructions for submitting data to NSW Department of Heath

■ Report the total number of SSIs of hip and knee

SSI in arthroplasties and CABG. These include

infections identified up to one month post-op for

superficial infections and up to one year post-op

for deep infections.

■ Enter data into the NSW Department of Health HAI

database within 30 days of the month following the

reporting period eg March data is due by 30th April.


■ Reports provided monthly.

Benchmarks

■ VICNISS (Victorian Nosocomial Infection Surveillance

System)

■ HISWA (Healthcare Infection Surveillance Western

Australia)

4.11 ICD-10-AM Codes for Arthroplasty

Arthroplasties of hip and knee included in this

surveillance are total, partial and revision arthroplasties.


Table 13: ICD-10-AM codes for hip arthroplasty (ACHS 2005)

Code DescriptionTotal

4931800 Total arthroplasty of hip, unilateral

4931900 Total arthroplasty of hip, bilateral

4932400 Revision of total arthroplasty of hip

4932700 Revision of total arthroplasty of hip with bone graft to acetabulum

4933000 Revision of total arthroplasty of hip with bone graft to femur

4933300 Revision of total arthroplasty of hip with bone graft to acetabulum and femur

4933900 Revision of total arthroplasty of hip with anatomic specific allograft to acetabulum

4934200 Revision of total arthroplasty of hip with anatomic specific allograft to femur

4934500 Revision of total arthroplasty of hip with anatomic specific allograft to acetabulum and femur

Partial

4931500 Partial arthroplasty of hip

4934600 Revision of partial arthroplasty of hip

Table 14: ICD-10-AM codes for knee arthroplasty (ACHS 2005)

Code Description4951700 Hemiarthroplasty of knee

4951800 Total arthroplasty of knee, unilateral

4951900 Total arthroplasty of knee, bilateral

4952100 Total arthroplasty of knee with bone graft to femur, unilateral

4952101 Total arthroplasty to knee with bone graft to femur, bilateral

4952102 Total arthroplasty to knee with bone graft to tibia, unilateral

4952103 Total arthroplasty to knee with bone graft to tibia, bilateral

4952400 Total arthroplasty of knee with bone graft to femur and tibia, unilateral

4952401 Total arthroplasty of knee with bone graft to femur and tibia, bilateral

4952700 Revision of total arthroplasty of knee

4953000 Revision of total arthroplasty of knee with bone graft to femur

4953001 Revision of total arthroplasty of knee with bone graft to tibia

4953300 Revision of total arthroplasty of knee with bone graft to femur and tibia

4953400 Total replacement arthroplasty of patellofemoral joint of knee

4955400 Revision of total arthroplasty of knee with anatomic specific allograft

Table 15: ICD-10-AM codes for coronary artery bypass grafts

Code Description1.5 – 1.8: Any procedure code(s) from blocks:

[672] Coronary artery bypass – saphenous vein graft

[673] Coronary artery bypass – other vein graft

[674] Coronary artery bypass – LIMA graft

[675] Coronary artery bypass – RIMA graft

[676] Coronary artery bypass – radial artery graft

[677] Coronary artery bypass – epigastric

artery graft

[678] Coronary artery bypass – other artery graft

[679] Coronary artery bypass – other material graft


Multi-resistant organisms (MRO) in ICU

SECTION 5

5.1 Rationale

This indicator is designed for monitoring acquisition

of MRO in Intensive Care Units (ICU). ICU patients are

often exposed to antibiotics and are at a higher risk of

acquiring MROs. Acquisition of MRO in ICU is a key

measure of the success of ICU MRO control measures.

To make this a more reliable measure, standardised

MRO screening processes are required in ICU. Refer to

Infection Control Policy: Prevention and management of

multi-resistant organisms (MRO) PD2007_084.

ICUs that have a high admitted burden of MRO

patients may experience greater difficulty with MRO

containment. The proportion of ICU admissions in which

MRO colonisation is detected at admission should be

analysed locally.


CI 4.1 Rate of methicillin-resistant Staphylococcus aureus (MRSA) acquisition in ICU

Numerator The total number of ICU - associated

MRSA acquisitions in reporting month

Denominator The total number of ICU bed days in

reporting month

CI 4.2 Rate of meropenem-resistant Acinetobacter baumannii (MRAB) acquisition in ICU

Numerator The total number of ICU - associated

MRAB acquisitions in reporting month

Denominator The total number of ICU bed days in

reporting month

5.3 Numerator data

■ Acquisition includes new infections and new colonisations

■ Table 16 provides a guide for the information to assist in the collection of the numerator. This information is not

required to be reported to NSW Department of Health.

Table 16: ICU MRO Acquisition Table

Data field Definition/Description ValidationHospital Name of hospital

Intensive care type Adult paediatric Neonatal ICUs are not required to submit this

indicator

If the ICU is a combined Paediatric/Adult facility

then specify ‘Adult’



Date of hospital

admission

Admission date prior to ICU admission Must not be after ICU admission date

Date of ICU admission Date of first ICU admission


5.5 Definition of terms

5.5.1 ICU

ICU includes adult and paediatric ICU

An ICU includes an ICU, CICU, CCU and HDU. Refer

to Intensive Care Coordinating and Monitoring Unit

website at http://intensivecare.hsnet.nsw.gov.au/five/htm/

definitions.php

Only include those NSW healthcare facilities that are

listed at this site http://intensivecare.hsnet.nsw.gov.au/

five/htm/locations.php

5.5.2 ICU bed days

Total number of bed days of all admitted patients

accommodated in ICU during the reporting period.

It is taken from the count of the number of inpatients

in ICU at midnight.

5.5.3 MRSA

Methicillin-resistant Staphylococcus aureus confirmed

by reference method. This includes non-multi-resistant

methicillin resistant strains (eg eMRSA, eMRSA15,

cMRSA) that are starting to appear in Australia.

■ All patients should be screened for MRSA

colonisation on admission to ICU. ICU MRSA

acquisition refers to patients not previously known

to be MRSA colonised and who are negative on

admission screening, who become colonised or

infected >48 hours after ICU admission

■ Patients detected with MRSA up to 48 hours after

ICU discharge are also counted as ICU-associated

acquisitions, regardless of whether the discharge

MRSA screens were negative.

■ Patients readmitted to ICU within 48 hours of ICU

discharge who test MRSA positive on ICU admission

screening are also counted as ICU acquisitions.

■ Patients who previously had MRSA and who have

been formally demonstrated to be ‘clear’ of MRSA

colonisation are counted as new acquisitions if

they become MRSA positive > 48 hours after ICU

admission or within 48 hours of ICU discharge.

Date when acquisition

was detected

Date the first positive specimen was

obtained

Must be > 2 days after date of ICU admission and

within 2 days of ICU discharge.

If patient has been previously colonised with the

MRO, then there must have been a period when

the patient was formally documented as ‘cleared’

prior to the acquisition point.

Organism ■ MRSA

■ MRAB

Lab specimen number Lab number assigned to the positive

specimen

Date of ICU discharge Date of discharge from ICU for the

ICU admission during which

acquisition occurred

For patients who are managed in step down

co-located HDU prior to discharge from ICU, then

take the date of discharge from the HDU.

Was ICU admission

screen for MRSA

attended?

Yes/no (for ICU admission that preceded

MRSA acquisition

Not required for MRAB acquisition.

Report date


Number of ICU bed days.



■ Prompt laboratory notification of new isolates of

MRSA and MRAB to ICPs to enable evaluation and

determination of ICU association status.


■ Compliance with admission, discharge and weekly

screening should be audited regularly.

■ If the MRO acquisition is a SA-BSI then this event is

recorded twice as “MRSA acquisition” AND “SA-BSI”.

■ Individual acquisition events reported once detected.

Separate reports for MRSA and MRAB in the

same patient.

5.8 Calculation of rate of MRO acquisition

MRO rate = Number of MRO acquisitions x 1,000

Number of ICU bed days




database within 30 days of the month following the

reporting period.

eg March data is due by 30th April.


Intensive Care MRO acquisition rates will be reported

against ICU bed-days .

Analysis: ■ Monthly MRSA, MRAB acquisition rate by Intensive care unit, stratified by each Area Health Service

Benchmarks: ■ South Australia ■ HISWA (Healthcare Infection Surveillance Western Australia) 5.11 ICD codes

■ ICD-10 codes: A41.0 Septicaemia due to

Staphylococcus aureus


NSW Health Healthcare-associated infections (HAI)

website http://www.health.nsw.gov.au/quality/hai/

O’Grady, NP, Alexander, M, Dellinger, EP 2002,

‘Guidelines for the prevention of intravascular

catheterrelated infections’, Morbidity and Mortality

Weekly Report, vol. 51, RR10, pp 126.

Mangram, AJ, Horan, TC, Pearson, ML et al 1999,

‘Guideline for the prevention of surgical site infection

1999’, Infection Control and Hospital Epidemiology, vol.

20, no. 4, pp 250–278.

Boyce, JM & Pittet, D 2002, ‘Guideline for hand hygiene

in healthcare settings’, Morbidity and Mortality Weekly

Report, vol. 51, no. RR16, pp. 144.

Department of Health, 2001, ‘Guidelines for preventing

infections associated with the insertion and maintenance

of short term urethral catheters in acute care’, Journal of

Hospital Infection, vol. 47 (Supplement): S39–S46.

Centres for Medicare & Medicaid Services – Surgical

Infection Prevention http://www.medqic.org/sip

VICNISS – Type 2 Surveillance Manual http://www.vicniss.

org.au/HCW/Type2/Manual.aspx

HISWA Healthcare Infection Surveillance Western

Australia http://www.public.health.wa.gov.au/3/277/3/

surveillance.pm

Morton AP, Whitby M, McLaws M et al. The application

of statistical process control charts to the detection and

monitoring of hospital-acquired infections. Journal of

Quality in Clinical Practice 2001;21:112-117.

NSW Health Infection Control Policy: Prevention and

Management of Multi-Resistant Organisms (MRO)

PD2007_084.

AICA-NAB/ Australian Council for Healthcare Quality

and Safety: Multi-resistant organism surveillance

indicators http://www.safetyandquality.org/internet/

safety/publishing.nsf/Content/former-pubs-archive-

hcai-definitions

References

SECTION 6


Table 17: NSW Health Healthcare associated infections (HAI) clinical indicators

Central-line associated bloodstream infections (CLAB) in ICUCentral Line Associated Bloodstream (CLAB) infections in ICU

CI 1.1

CI 1.2

CI 1.3

CI 1.4

■ Rate of adult ICU-associated centrally-inserted (CI) CLAB infection■ Rate of paediatric ICU-associated centrally-inserted (CI) CLAB infection■ Rate of adult ICU-associated peripherally-inserted (PI) CLAB infection■ Rate of paediatric ICU-associated peripherally-inserted (PI) CLAB infection

Staphylococcus aureus bloodstream infections (SA-BSI) CI 2.1

CI 2.2

CI 2.3

CI 2.4

CI 2.5

CI 2.6

■ Rate of healthcare associated (in-patient) methicillin sensitive Staphylococcus aureus

bloodstream infections.■ Rate of healthcare associated (in-patient) methicillin-resistant Staphylococcus aureus

bloodstream infections.■ Rate of healthcare associated (non in-patient) methicillin sensitive Staphylococcus aureus

bloodstream infections.■ Rate of healthcare associated (non in-patient) methicillin resistant Staphylococcus aureus

bloodstream infections.■ The number of community-associated methicillin-sensitive Staphylococcus aureus (MSSA)

bloodstream infections.■ The number of community-associated methicillin-resistant Staphylococcus aureus (MRSA)

bloodstream infections.

Surgical site infections (SSI) – hip arthroplasty, knee arthroplasty and coronary artery bypass grafts (CABG)CI 3.1

CI 3.2

CI 3.3

CI 3.4

CI 3.5

CI 3.6

■ Rate of superficial incisional SSI following hip arthroplasty■ Rate of deep incisional/organ space SSI following hip arthroplasty■ Rate of superficial incisional SSI following knee arthroplasty■ Rate of deep incisional/organ space SSI following knee arthroplasty■ Rate of superficial incisional sternal site SSI following coronary artery bypass grafts■ Rate of deep incisional sternal site/organ space SSI following coronary artery bypass grafts.

Multi-resistant organisms (MRO) in ICUCI 4.1

CI 4.2

■ Methicillin-resistant Staphylococcus aureus (MRSA) acquisition in ICU■ Meropenem-resistant Acinetobacter baumannii (MRAB) acquisition in ICU

Appendices

SECTION 7


The Quality and Safety Branch wishes to acknowledge

and thank those who provided their expertise and

valuable time in the review of this manual. In particular,

Professor Lyn Gilbert, Dr John Ferguson, members of

the HAI Indicator Manual and HAI Prevention Working

Parties, the HAI Expert Advisory Group and those who

provided feedback during the consultation process.

Acknowledgements

SECTION 8

SHPN: (QSB) 080136

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Healthcare Associated Infection...PaGe 2 NSW HealtH Healthcare associated Infection (HaI) Clinical Indicators – Manual Surveillance is an essential component and the only rational