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INFECTION CONTROL AND SURVEILLANCE“An ounce of prevention is worth a pound of
cure.”
Learning Objectives
1. Define infection and nosocomial infection.
2. States the meaning of infection control.
3. Explain the organization of infection control program.
4. Discuss the major components of an infection control program.
5. Describe a surveillance of HAIs.
INTRODUCTION – INFECTION AND NOSOCOMIAL INFECTION
Infection is an invasion of pathogens or microorganisms into the body those are capable
of producing disease.
Nosocomial infection - also called “Hospital acquired infections” or “Healthcare
Associated Infection (HAI)”
An infection acquired in hospital by a patient or staff member while in a hospital or health
care facility
It includes infections -
not present nor incubating at admission,
infections that appear more than 48 hours after admission,
those acquired in the hospital but appear after discharge
also occupational infections among staff.
INFECTION CONTROL
“The process by which health care facilities develop and implement specific policies and
procedures to prevent the spread of infections among health care staff and patients.”
Infection Control includes all of the practices used to prevent the spread of
microorganisms that could cause disease in a person.
Prevention of nosocomial infection is the responsibility of all individuals and services
provided by healthcare setting.
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Why Infection Control?
Hospital acquired infections are a common problem—prevalence about 5-10% in
developed countries and about 25% in developing countries.
Hospital acquired infections contribute to AMR (antimicrobial resistance)
Overuse of antimicrobials (development)
Poor infection control practices (spread)
Hospital-acquired infections increase the cost of health care
World Bank studies have shown that two-thirds of developing countries spend
more than 50% of their health care budgets on hospitals
Effective Infection Control programs are beneficial
They decrease spread of nosocomial infections, morbidity, mortality, and health
care costs.
INFECTION CONTROL PROGRAM
It is a comprehensive, effective and supported program is essential for reducing infection
risk and increasing hospital safety.
At national level – the programme is developed by Ministry of Health, to support
hospital programs. It sets national objectives, develops and updates guidelines
recommended for health care.
In hospital infection control programme – The major preventive effort should be
focused in hospitals and other health care facilities.
Risk prevention for patients and staff is a concern of everyone in the facility.
It must be supported by senior management and provided with sufficient
resources.
It is develop and manage by the infection control committee, infection control
team and infection control manual as per the national guidelines, recommendation.
It must develop a yearly work plan to assess and promote all good health care
activities.
It includes the preventive activities, staff training and surveillance.
ORGANIZATION OF AN INFECTION CONTROL PROGRAMME
As with all other functions of a health care facility, the ultimate responsibility for
prevention and control of infection rests with the health administrator.
The hospital administrator/head of hospital should:
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Establish an infection control committee which will in turn appoint an infection
control team; and
provide adequate resources for effective functioning of the infection control
programme.
INFECTION CONTROL COMMITTEE
An infection control committee provides a forum for multidisciplinary input and
cooperation, and information sharing and responsible for the development of policies for
the prevention and control of infection and to oversee the implementation of the infection
control programme.
This committee should -
be composed of representatives of various units within the hospital that have roles
to play: e.g. management, physicians, other health care workers, clinical
microbiology, pharmacy, sterilizing service, maintenance, housekeeping and
training services.
elect one member of the committee as the chairperson (who should have direct
access to the head of the hospital administration);
appoint an infection control practitioner (health care worker trained in the
principles and practices of infection control, e.g. a physician, microbiologist or
registered nurse) as secretary.
meet regularly (ideally monthly but not less than three times a year).
develop its own infection control manual/s; and
monitor and evaluate the performance of the infection control programme.
It has the following tasks:
To review and approve a yearly programme of activity for surveillance and
prevention;
to review epidemiological surveillance data and identify areas for intervention;
to assess and promote improved practice at all levels of the health facility;
to ensure appropriate staff training in infection control and safety management,
provision of safety materials such as personal protective equipment and products;
and
Training of health workers.
INFECTION CONTROL TEAM
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Health care establishments must have access to specialists in infection control,
epidemiology, and infectious disease, including physicians and infection control
practitioners.
These professionals are specialized teams working for a hospital or a group of health care
establishments; they may be administratively part of another unit (e.g. a microbiology
laboratory, medical or nursing administration, public health services).
The infection control team or individual is responsible for the day-to-day functions of
infection control, as well as preparing the yearly work plan for review by the infection
control committee and administration.
The infection control team should:
Consist of at least an infection control practitioner who should be trained for the
purpose;
carry out the surveillance programme;
develop and disseminate infection control policies;
monitor and manage critical incidents;
Coordinate and conduct training activities.
INFECTION CONTROL MANUAL
A hospital-associated infection prevention manual containing instructions and practices
for patient care is an important tool.
The manual should be developed and updated by the infection control team and reviewed
and approved by the committee.
It must be made readily available for health care workers, and updated in a timely
fashion.
COMPONENTS OF INFECTION CONTROL PROGRAMME
Infection Control Programme
Preventive activities Staff training Surveillance
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PREVENTIVE ACTIVITY
Basic measures for Infection Control Practices
Standard precautions
Hand hygiene
Using personal protective equipment
Safe handling and disposal of sharps
Safe handling and disposal of chemical waste
Managing blood and bodily fluids
Spillages
Collecting, handling and labelling of specimens
Decontaminating equipment
Cleaning
Disinfection
Sterilisation
Achieving and maintaining a clean clinical environment
Additional (Transmission-Based) Precautions
Airborne precautions;
Droplet precautions; and
Contact precautions.
Appropriate use of indwelling devices
Managing accidental exposure to blood-bornes (PEP-Post exposure prophylaxis)
Staff health and immunization
EDUCATION AND TRAINING OF HEALTH CARE STAFF
Health administrators should be oriented towards the importance of the infection control
programme.
Health care workers should be equipped with requisite knowledge, skills and attitudes for
good infection control practices.
The infection control team should:
Assess training needs of the staff and provide required training through awareness
programmes, in-service education and on-the-job training;
organize regular training programmes for the staff for essential infection control
practices that are appropriate to their job description;
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provide periodic re-training or orientation of staff; and review the impact of
training.
SURVEILLANCE
Surveillance is an essential component of an effective infection prevention and control
program.
“Ongoing collection, collation, and analysis of data and the ongoing dissemination of
information to those who need to know so that action can be taken.”
“Ongoing, systematic collection, analysis and interpretation of health data essential to
planning, implementation and evaluation of public health services; closely integrated with
timely dissemination of the data to those who need to know about it”.
NEED FOR SURVEILLANCE
It require for improvements in health care with increased quality and safety but changes
in care with new techniques, New pathogens or changes in resistance, increased patient
acuity, ageing population, etc. so, need for active surveillance to monitor changing
infectious risks and identify needs for changes in control measures.
GOAL
Surveillance, as part of infection prevention and control programs in health care facilities,
contributes to meeting the program’s overall goals: protect the patient; protect the health
care worker, visitors, and others in the health care environment; and accomplish these two
goals in a timely, efficient, and cost-effective manner.
PURPOSE OF SURVEILLANCE
Reducing infection rate within hospital
Establishing endemic baseline rates
Identifying outbreaks
Convincing medical staff
Evaluating control measures
Convincing Planners, Media & People
Defending Hospital procedures- legal aspects
Comparing rates between hospitals
OBJECTIVES
The ultimate aim is the reduction of nosocomial infections, and their costs.
The specific objectives of a surveillance programme include:
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to improve awareness of clinical staff and other hospital workers (including
administrators) about nosocomial infections and antimicrobial resistance, so they
appreciate the need for preventive action
to monitor trends: incidence and distribution of nosocomial infections, prevalence
and, where possible, risk-adjusted incidence for intra- and inter-hospital
comparisons
to identify the need for new or intensified prevention programmes, and evaluate
the impact of prevention measures
to identify possible areas for improvement in patient care, and for further
epidemiological studies (i.e. risk factor analysis).
CHARACTERISTICS OF SURVEILLANCE SYSTEM
A surveillance system must meet the following criteria
Characteristics of the system:
timeliness, simplicity, flexibility
acceptability, reasonable cost
representativeness (or exhaustiveness)
Quality of the data provided:
sensitivity, specificity
predictive value (positive and negative)
usefulness, in relation to the goals of the surveillance (quality indicators)
COMPONENTS OF A STRONG SURVEILLANCE PROGRAM
Should be based on sound epidemiological and statistical principles
Designed in accordance with current recommended practices
Needs to be able to identify risk factors for infection
Adverse events
Implement risk-reduction measures
Monitor the effectiveness of intervention
Should be able to Identify the-
Outbreaks
Emerging infectious diseases
Antibiotic-resistant organisms
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Surveillance data will be used to reduce the occurrence of infections by using risk factors
and implementation of risk-reduction measures and monitoring effectiveness of
interventions.
FACTORS AFFECTING SURVEILLANCE PROGRAMS
Shorter hospital stays
Aging of the population
Increased use of invasive procedures and devices
More acutely ill patients and residents
Healthcare worker shortage
Emerging and re-emerging infectious diseases
Mandatory and public reporting
New diseases emerging
Antimicrobial resistance
Mandatory reporting requirements increase
New surveillance methods are needed to meet the changing environment
ESSENTIAL ELEMENTS OF SURVEILLANCE
1) Assess the population and identify those individuals at greatest risk for the outcome (e.g.,
bloodstream infection) or process (e.g., central line insertion practices) of interest
a) Healthcare-associated infections (HAIs) (outcomes)
b) Patient care practices aimed to prevent HAIs (processes)
2) Select the appropriate outcome or process to be monitored by surveillance
a) Examples of outcomes: HAI, infection or colonization by a specific organism,
pyrogenic reaction or vascular access infection in hemodialysis patients, and sharps
injuries
b) Examples of processes: Central line insertion practices (CLIPs), surgical care
processes (e.g., preoperative antimicrobial prophylaxis), medication errors, influenza
vaccination rates, hepatitis B immunity rates, and personnel compliance with
protocols
c) Examples of other events: Occurrence of reportable diseases and conditions,
communicable diseases in personnel, and organisms or syndromes indicative of
bioterrorist events
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3) Determine the observation time period: This time period should be appropriate for
collecting sufficient data and may be affected by factors like hospital resources, hospital
size, target population, and healthcare priorities.
4) Choose the surveillance methodology
5) Monitor for the outcome or process using standardized definitions for all data collected
6) Collect appropriate denominator data if rates are to be calculated
7) Analyse surveillance data
8) Report and use surveillance information in a timely manner
LOCATION OF SURVEILLANCE
The patient care area to which a patient is assigned while receiving care in the healthcare
facility. The location of surveillance may be inpatient, outpatient, or both.
Inpatient locations: Locations serving patients whose date of admission to the healthcare
facility and the date of discharge are different calendar days.
1. Intensive care units - that provides intense observation, diagnosis, and therapeutic
procedures, includes Adult ICU, PICU, NICU etc.
2. Specialty care area (SCA): bone marrow transplant, solid organ transplant, inpatient
acute dialysis, hematology/oncology, or long term acute care.
3. Other inpatient: This section includes any inpatient locations that do not have an ICU
or SCA, e.g., inpatient medical, surgical, or other wards, step-down units, or operating
rooms (ORs). The OR may include an operating room, C-section room, interventional
radiology room, a cardiac catheterization lab, or a post-anesthesia care unit.
Outpatient locations: These locations serve patients whose date of admission to the
healthcare facility and the date of discharge are the same calendar day. These may include
any outpatient clinic, the Outpatient Emergency Department, or same day surgery and its
24-hour observation area.
Other locations include:
NON-PATIENT CARE LOCATIONS: e.g., laboratory or laundry
TYPES OF SURVEILLANCE
Total or Whole House Surveillance
Monitors all HAI in the entire facility
Overall facility infection rate should not be calculated
Rates should be calculated for specific AHIs in a defined population
Overall facility rates are not sensitive enough to identify potential problems
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Are not adjusted for specific infection or injury risks so they are not appropriate for:
measuring trends over time
Comparisons between groups
Benchmarking
Although ideal most facilities do not have the technical and personnel resources to do
house-wide surveillance
Advantages:
Provide Complete picture
Disadvantages:
Unrealistic
Require Manpower
Not related to specific goals
Collection of data for sake of collection
Target surveillance
Target surveillance is generally conducted
1990 CDC shifted from total house surveillance to target surveillance
Based on facility-specific risk assessment
Focuses on:
particular care units (e.g., ICU, nurseries etc)
Infections related to devices (e.g., intravascular and urinary catheters)
Invasive procedures (e.g., surgery)
Organisms (e.g., resistant organisms such as MRSA, VRE, ESBL, etc)
Focuses on high-risk, high-volume procedures and adverse outcomes that are
potentially preventable
Advantages:
Surveillance based on identified risks
Best use of limited resources
Risk adjusted & comparative national rates available
Disadvantages:
Limited knowledge of facility norms
Recent trends in “targeted surveillance” include:
Site-oriented surveillance:
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Priorities will be to monitor frequent infections with significant impact in
mortality, morbidity, costs (e.g. extra hospital days, treatment costs), and which
may be avoidable.
Common priority areas are:
ventilator-associated pneumonia (a high mortality rate)
surgical site infections (first for extra-hospital days and cost)
primary (intravascular line) bloodstream infections (high mortality)
multiple-drug resistant bacteria (e.g. methicillin-resistant Staphylococcus
aureus, Klebsiella spp. with extended-spectrum beta-lactamase).
This surveillance is primarily laboratory-based. The laboratory also provides units
with regular reports on distribution of microorganisms isolated, and antibiotic
susceptibility profiles for the most frequent pathogens.
Unit-oriented surveillance:
efforts can focus on high-risk units such as intensive care units, surgical units,
oncology/haematology, burn units, neonatalogy, etc.
Priority-oriented surveillance:
Surveillance undertaken for a specific issue of concern to the facility (i.e. urinary
tract infections in patients with urinary catheters in long-term care facilities).
While surveillance is focused in high-risk sectors, some surveillance activity
should occur for the rest of the hospital. This may be most efficiently performed
on a rotating basis (laboratory-based or repeated prevalence studies).
Active and passive surveillance
Active surveillance
Trained personnel, mainly ICPs, are vigorously look for HAIs
Information is accumulated using a variety of data sources within and beyond the
nursing ward
Passive surveillance
Persons who do not have a primary surveillance role, such as ward nurses or
respiratory therapists, identify and report HAIs
Patient-based and laboratory-based surveillance
Patient-based surveillance
Count HAIs, assess risk factors, and monitor patient care procedures and practices
for adherence to infection control principles
Requires ward rounds and discussion with caregivers
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Laboratory-based surveillance
Detection is based solely on the findings of laboratory studies of clinical
specimens.
Prospective and retrospective surveillance
Prospective surveillance
Monitor patients during their hospitalization
For SSIs, also monitor during the post-discharge period
Retrospective surveillance
Identify infections via chart reviews after patient discharge
Priority-directed and comprehensive surveillance
Priority-directed surveillance (also called targeted or focused surveillance)
Objectives for surveillance are defined
The focus is on specific events, processes, organisms, and/or patient populations
Comprehensive surveillance
Continuous monitoring of all patients for all events and/or processes
Highly personnel resource intensive if done manually
SURVEILLANCE DATA COLLECTION
The data collected may be numerator or denominator data.
Numerator: the upper portion of a fraction used to calculate a rate or ratio. In surveillance,
it is usually the number of cases of a disease or event being studied.
Denominator: the lower portion of a fraction used to calculate a rate or ratio.
Example: 5 UTIs/135 Catheter Days = rate
5 is the Numerator 135 is the Denominator
Numerator Data Collection
Personnel other than infection control professionals (ICP) may be trained to screen data
sources for HAI, or automated screening of electronic databases may be used, as long as the
ICP makes the final determination of presence of HAI according to the criteria for defining
HAI.
Numerator data to collect
Demographics – name, date of birth, gender, hospital identification number,
admission date
Infection – onset date, site of infection, patient care location of HAI onset
Risk factors – devices, procedures, and other factors associated with HAI
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Laboratory – pathogens, antibiogram, serology, and pathology
Radiology/imaging – X-ray, CT scan, MRI, etc.
Sources of numerator data
Admission/discharge/transfer records and microbiology laboratory records
Visits to patient wards for observation and discussion with caregivers
Patient charts (paper or computerized) for case confirmation
Laboratory and radiology/imaging results
Nursing and physician’s notes and consults
Admission diagnosis
History and physical examination findings
Records of diagnostic and surgical interventions
Temperature chart
Information on administration of antibiotics
For post-discharge-detected SSI, sources include records from surgery clinics,
physicians’ offices, and emergency departments.
How an ICP collects numerator data
Screens admission/discharge/transfer records for patients who were admitted with
infection and those whose diagnoses put them at risk of acquiring an HAI
Reviews laboratory reports to look for patients with possible infections (e.g.,
positive microbiology cultures, positive pathology findings) and discusses with
laboratory personnel to identify both patients who may be infected and clusters of
infections, especially in areas not targeted for routine HAI surveillance
During ward rounds, quickly screens nursing care reports, temperature charts,
antibiotic administration sheets, and converses with nurses and physicians to
identify patients who may be infected
Performs chart review of patients who are suspected of having HAI: reviews
physicians’ progress notes and nurses’ notes, laboratory data, radiology/ imaging
reports, surgery reports, etc.; if electronic charts are available, these charts can be
reviewed from the ICP’s desk, but ward rounds are still essential for surveillance,
prevention, and control activities
Completes HAI data collection forms/screens as data sources are reviewed
Denominator Data Collection
Denominator data may be collected by someone other than the ICP as long as that person is
trained. When denominator data are available from electronic databases (e.g., patient tracking
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systems, respiratory therapy database), these sources may be used as long as the counts are
not substantially different from those collected manually.
Denominator data to collect
Counts of the cohorts of patients at risk for acquiring an HAI
Device-associated Bloodstream Infection (BSI), Ventilator-Associated Pneumonia
(VAP), and Urinary Tract Infection (UTI) incidence density rates: record on a
daily basis the total number of patients and total number of ventilator-days, central
line-days, and urinary catheter-days in the patient care area(s) under surveillance;
sum these daily counts at the end of the surveillance period for use as
denominators
Dialysis Event (DE): record the number of chronic hemodialysis patients with
each access type who received hemodialysis at the center during the first two
working days of the month
Antimicrobial Use and Resistance (AUR)-microbiology: record the number of
tested isolates
AUR-pharmacy: record the patient-days for in device-associated HAIs
Surgical Site Infection (SSI) or Post-Procedure Pneumonia (PPP): record
information on operative procedures selected for surveillance (e.g., type of
procedure, date, risk factors)
Sources of denominator data
Device-associated BSI, VAP, and UTI incidence density rates: visits to patient
care areas to obtain daily counts of the number of patients admitted and the
number of patients with each commonly used devices associated with HAI (i.e.,
one or more central line, ventilator, or indwelling urinary catheter)
DE: visits to patient hemodialysis outpatient clinics to obtain monthly counts of
chronic hemodialysis patients served
AUR-microbiology: process laboratory reports
AUR-pharmacy: total patient-days as shown in device-associated HAIs
For SSI or PPP rates: detailed logs from the operating room for each operative
procedure
How an ICP collects denominator data
For device-associated incidence density rates: records daily counts of the number
of patients admitted and the number of patients with each of the commonly used
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devices associated with HAI (i.e., one or more central line, ventilator, or
indwelling urinary catheter)
For SSI rates: obtains data on operations from operating room logs and patient
charts as needed
SURVEILLANCE DATA ENTRY
Collect only necessary data
Record data in a systematic formatting
Organize data in a meaningful way:
Flow sheet or line-list.
Computer data-base (excel, Epi-info, SPSS or STATA).
SURVEILLANCE DATA ANALYSIS
Put the results of data collected into rates and ratios: A / B x 100 or 1000
For the numerator A use the number of nosocomial infection in particular group at risk.
For the denominator B you may use one of the following:
Number of admission or discharge in an interval
Number of person undergoing a procedure
Patient-days in the hospital or on a particular unit
Number of device-days
Approach for analysis of data :
Defining and calculating rates
Prevalence which include point prevalence and period prevalence
Both types count active cases of a disease in a defined population
Incidence which is the total number of a new cases of disease that occurs
among given population during a specified period of time
Comparing rates among patient groups
The denominator must reflect the population at risk
Intrinsic risk factors
Extrinsic risk factors
Comparing rates overtime
The importance is risk related as major risks varies overtime
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e.g. SSI are getting less than before as of hospital stay is getting
less
Identifying outbreaks
Looking at your trends
Assessing appropriateness of medical care
Comparing different devices
DISSEMINATION OF DATA
Data should not be used for punitive purposes but rather to augment quality improvement
efforts.
Narrative summaries and tabular graphic reports of surveillance data will be provided to
the hospital infection control committee, executive director, general manager and head of
departments.
BENCHMARKING
Benchmarking is the process of comparing oneself to others who are performing similar
activities, so as to continuously improve. The National Healthcare Safety Network (NHSN)
in the US is the oldest and most widely used network for benchmarking. Although it is very
appealing to compare one’s rates externally with others’ rates, the comparisons should be
made only after ensuring that the following conditions are met:
Criteria for defining a case are standardized and up to date.
Criteria are consistently used by all participants and all data collectors.
The population and time period for the study are well defined.
The surveillance methodology is standardized and consistently used by all of the
participants over time.
Rates and ratios are calculated using the same numerators (number of cases) and
denominators (population at risk).
The size of the population studied (denominator) is large enough to provide an accurate
estimate of the true rate.
A standardized risk adjustment method is used by all of the participants.
All data collectors receive training on how to collect data and use a standardized form.
The facility and population that is compared is similar to the types of facilities and
populations in an aggregate database used for external comparison (for example, data
from a neonatal ICU is compared with data aggregated from other neonatal ICUs).
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There is a mechanism for ensuring the accuracy, sensitivity, and specificity of the
collected data.
The analysis and interpretation of the data provided by the benchmarking system is
accurate and in a form that is understandable to the users.
Feedback will be disseminated to those who can affect change.
The data provided by the GCC Center for Infection Control to external similar bodies
(e.g., NHSN) are coded for confidentiality, and the reports provided to these bodies or to
the public do not contain facility identifiers
SURVEILLANCE REPORTING
A written report should be developed to provide a mechanism to interpret and disseminate
surveillance data to stimulate performance improvement activities. Tables, graphs, and charts
are effective tools for organizing, summarizing, and visually displaying data and should be
used as applicable. The format and level of detail in each report will depend on the intended
audience.
A surveillance report should:
1. Define the event, population, setting, and time period studied (e.g., surgical site
infections in patients undergoing coronary artery bypass graft in hospital A from
January through December 2013)
2. State the criteria used for defining a case (e.g., NNIS criteria for urinary tract
infection)
3. Specify the number of cases or events identified and the number in the population
studied (e.g., 2 surgical site infections occurred during 179 total hip replacement
procedures)
4. Explain the methodology used to identify the cases (e.g., case reports from personnel
and review of medical records and laboratory results)
5. Identify the statistical methods and calculations used, when appropriate (e.g., fall rate
in April = falls in April / # resident days in April x 1,000 or 3/414 x 1,000 =7.2 falls
per 1,000 resident-days)
6. State the purpose for conducting surveillance (e.g., to reduce the rate of occurrence of
an event)
7. Interpret the findings in a manner that is understandable to those who read the report
8. Describe any actions taken and recommendations made for prevention and control
measures
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9. Identify the author and date of the report
10. Identify the recipients of the report
Mechanism of reporting:
After you prepare the report according to the above criteria (including conclusions and
recommendations that are easy to understand), the following persons/bodies need to receive a
copy of your final report:
1. Immediate supervisor, higher ranking administration, or any other healthcare facility
employee who is required (by your facility’s local policies) to be informed and/or are
authorized to implement the suggested recommendation.
2. Ministry of Health or even higher national or international bodies (according to your
country’s health policies regarding certain outbreaks).
3. Healthcare workers who have immediate concerns about the report contents (e.g., the
surgical team that performed the procedures for which you are reporting SSI rates)
4. ICPs that are directly involved in data collection as a way to keep them informed as
well as promote quality improvements.
SUMMARY
As the health workers are having more risk to get infected while providing care to the
patients, it is necessary for them to have a proper knowledge and attitude regarding
infection control. Poor knowledge can put them in risk so they must compulsorily
follow the universal precautionary measures like hand hygiene, sterilization and
disinfection procedures, use of personal protective equipment, biomedical waste
management and post exposure prophylaxis. In this way we can reduce the incidence
of health care associated infections.
Surveillance practices evolve in response to changes in healthcare delivery. The use
of surveillance data has shifted from measuring clinical outcomes, such as infections,
to guiding performance improvement activities and demonstrating improvements in
clinical outcomes and healthcare practices. With the increase of antimicrobial
resistance and outbreaks caused by emerging and re-emerging infectious diseases and
intentionally released pathogens highlights the need for local, regional, national, and
global surveillance systems.
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ICPs responsible for managing surveillance programs must ensure that their programs
are based on sound epidemiological and statistical principles and designed and
evaluated in accordance with current recommendation and practices and have the
resources needed to promote quality healthcare.
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