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[Non-Text] الشراه المحده Ministry of Health KINGDOM OF SAUDI ARABIA Ministry of Health- Riyadh KSA General Directorate of Infection Prevention and Control [Non-Text] GDIPC Surveillance Healthcare Associated Infections (HAIs) Surveillance Manual Second Edition Contributors and Collaborators Contributors: Dr. Faisal AlSheddi Director of HAIs Surveillance Program, GDIPC MOH Dr. Tabish Humayun HAI Surveillance Coordinator, GDIPC MOH Yvonne Suzette A. Aldecoa HAI Surveillance Coordinator, GDIPC MOH Wafa Al Shammari HAI Surveillance Coordinator, GDIPC MOH Dr. Nasser Al Sherif Former HAIs surveillance training and education Coordinator, GDIPC, MOH Dr. Aiman El Saeed Ramadan Advisor, HAI Surveillance MNGHA Collaborators: Dr. Muhammad Raees Malik HAIs Surveillance Regional Coordinator, Qassim Dr. Ali Ahmad Al Radaidah HAI Surveillance Regional Coordinator, Al Jouf Ms. Ashwaq Abdulghani Qawas HAI Surveillance Regional Coordinator, Makkah Dr. Mohammed Al Qahtani HAI Surveillance Coordinator, GDIPC MOH Fayez Al Dalbehi HAI Surveillance Coordinator, GDIPC MOH Dr. Sameh Tawfik HAI Surveillance Coordinator, GDIPC MOH Hind Al Anazi HAI Surveillance Coordinator, GDIPC MOH Adel Al Anazi Former HAls surveillance Coordinator, GDIPC, MOH Dr. Ghada Al Saleh Former Head of Surveillance and Outbreak Program GDIPC MOH Dr. Mohamed Ahmed Mirghani HAI Surveillance Regional Coordinator, Tabuk Dr. Faizah Rasheed HAI Surveillance Regional Coordinator, Riyadh Mr. Ahmed Jurayyad Sameer Alorfi HAI Surveillance Regional Coordinator, Madinah MOH Surveillance Manual II Last updated: November 2023 ® 2023 Ministry of Health, Riyadh, Saudi Arabia MOH Surveillance Manual III Last updated: November 2023 Message from General Director I am honored to present the second edition of healthcare-associated infections surveillance manual from the General Directorate of Infection Prevention and Control at the Ministry of Health. It has been estimated that 5% to 15% of the patients admitted to healthcare facilities may acquire infections while receiving care at these facilities. Most of these infections can be prevented by adherence to evidence-based infection control practices and care bundles designed to prevent these infections. The current edition aimed at guiding healthcare workers in Saudi Arabia, especially infection control practitioners, while monitoring healthcare-associated infections across different levels of healthcare facilities. Implementing the definitions and methodology described in this edition will ensure standardized surveillance and fair comparisons of infection rates and preventive practices between different facilities and in the same facility overtime. The second edition included several modifications based on the feedback of fellow professionals. We hope this manual will help and guide the infection control practitioners to better understand the surveillance definitions, methodology and other related topics which will enhance patient safety and improve patients' outcomes. Dr. Khalid H. Alanazi Director General, General Directorate of Infection Prevention and Control, Ministry of Health, Saudi Arabia. MOH Surveillance Manual IV Last updated: November 2023 Abbreviations <table><tr><td>ABUTI</td><td>ASYMPTOMATIC BACTEREMIC UTI</td></tr><tr><td>AIDS</td><td>Acquired immunodeficiency syndrome</td></tr><tr><td>ANC</td><td>Absolute neutrophil count</td></tr><tr><td>APIC</td><td>Association for Professionals in Infection Control and Epidemiology</td></tr><tr><td>APRV</td><td>Airway pressure release ventilation</td></tr><tr><td>ASA</td><td>American Society of Anesthesiology</td></tr><tr><td>ASC</td><td>Active surveillance cultures</td></tr><tr><td>ASP</td><td>Antimicrobial stewardship program</td></tr><tr><td>AST</td><td>Active surveillance testing</td></tr><tr><td>AUR</td><td>Antimicrobial Use and Resistance</td></tr><tr><td>AVF</td><td>Arteriovenous fistula</td></tr><tr><td>AVG</td><td>Arteriovenous graft</td></tr><tr><td>BAL</td><td>Broncho alveolar lavage</td></tr><tr><td>C. DIFF</td><td>Clostridium difficile</td></tr><tr><td>CAUTI</td><td>Catheter-associated urinary tract infection</td></tr><tr><td>CBAHI</td><td>Central Board for Accreditation of Healthcare Institutes</td></tr><tr><td>CCU</td><td>Coronary care unit</td></tr><tr><td>CDC</td><td>Centers for Disease Control and Prevention</td></tr><tr><td>CDI</td><td>Clostridium difficile infections</td></tr><tr><td>CFU</td><td>Colony forming units</td></tr><tr><td>CHG</td><td>Chlorhexidine gluconate</td></tr><tr><td>CLABSI</td><td>Central line-associated bloodstream infection</td></tr><tr><td>CLIPS</td><td>Central line insertion practice</td></tr><tr><td>CO</td><td>Community-onset</td></tr><tr><td>COVID-19</td><td>Coronavirus disease 2019</td></tr><tr><td>CPAP</td><td>Continuous nasal positive airway pressure</td></tr><tr><td>CRE</td><td>Carbapenem-resistant Enterobacteriaceae</td></tr><tr><td>CRKP</td><td>Carbapenem-resistant Klebsiella pneumonia</td></tr><tr><td>CSF</td><td>Cerebrospinal fluid</td></tr><tr><td>DE</td><td>Dialysis event</td></tr><tr><td>DOE</td><td>Date of event</td></tr><tr><td>DUR</td><td>Device utilization ratio</td></tr><tr><td>DVT</td><td>Deep venous thrombosis</td></tr><tr><td>ECDC</td><td>European Centre for Disease Prevention and Control</td></tr><tr><td>ECMO</td><td>Extracorporeal life support</td></tr></table> MOH Surveillance Manual V Last updated: November 2023 <table><tr><td>ELISA</td><td>Enzyme-linked immunoassay</td></tr><tr><td>EMR</td><td>Electronic Medical Record</td></tr><tr><td>ENT</td><td>Ear, nose, and throat</td></tr><tr><td>ETA</td><td>Endotracheal aspirate</td></tr><tr><td>FIO2</td><td>Fraction of inspired oxygen</td></tr><tr><td>GCC</td><td>Gulf Cooperation Council</td></tr><tr><td>GDIPC</td><td>General Directorate of Infection Prevention and Control</td></tr><tr><td>GIT</td><td>Gastrointestinal tract</td></tr><tr><td>GVHD</td><td>Graft versus host disease</td></tr><tr><td>HAI</td><td>Healthcare-associated infection</td></tr><tr><td>HCW</td><td>Health care workers</td></tr><tr><td>HD</td><td>Hemodialysis</td></tr><tr><td>HERO</td><td>Hemodialysis reliable outflow</td></tr><tr><td>HESN</td><td>Health electronic surveillance network</td></tr><tr><td>HFO</td><td>High frequency oscillatory</td></tr><tr><td>HIV</td><td>Human immunodeficiency virus</td></tr><tr><td>HO</td><td>Healthcare facility-onset</td></tr><tr><td>HSCT</td><td>Hematopoietic stem cell transplantation</td></tr><tr><td>IABP</td><td>Intra-aortic balloon pump</td></tr><tr><td>ICP</td><td>Infection control professional</td></tr><tr><td>ICU</td><td>Intensive care unit</td></tr><tr><td>IDSA</td><td>Infectious Diseases Society of America</td></tr><tr><td>INICC</td><td>The International Nosocomial Infection Control Consortium</td></tr><tr><td>IP</td><td>Infection preventionist</td></tr><tr><td>IPC</td><td>Infection prevention and control</td></tr><tr><td>IPCAF</td><td>WHO infection prevention and control assessment framework</td></tr><tr><td>IT</td><td>Information technology</td></tr><tr><td>IVAC</td><td>Infection-related ventilator-associated complications</td></tr><tr><td>IWP</td><td>Infection Window Period</td></tr><tr><td>KAP</td><td>Knowledge, attitude and practice</td></tr><tr><td>LABID</td><td>Laboratory-Identified</td></tr><tr><td>LCBI</td><td>Laboratory-confirmed bloodstream infection</td></tr><tr><td>MAP</td><td>Mean airway pressure</td></tr><tr><td>MBI</td><td>Mucosal barrier injury</td></tr><tr><td>MDR</td><td>Multidrug-resistant</td></tr><tr><td>MDRO</td><td>Multidrug-resistant organisms</td></tr><tr><td>MOH</td><td>Ministry of Health</td></tr></table> MOH Surveillance Manual VI Last updated: November 2023 <table><tr><td>MRSA</td><td>Methicillin-resistant staphylococcus aureus</td></tr><tr><td>MSSA</td><td>Methicillin-sensitive staphylococcus aureus</td></tr><tr><td>NHSN</td><td>National Healthcare Safety Network</td></tr><tr><td>NICU</td><td>Neonatal intensive care unit</td></tr><tr><td>OR</td><td>Operating room</td></tr><tr><td>PCR</td><td>Polymerase chain reaction</td></tr><tr><td>PEDVAE</td><td>Pediatric ventilator-associated event</td></tr><tr><td>PEEP</td><td>Positive end-expiratory pressure</td></tr><tr><td>PICU</td><td>Pediatric intensive care unit</td></tr><tr><td>PPE</td><td>Personal protective equipment</td></tr><tr><td>PPS</td><td>Point prevalence survey</td></tr><tr><td>PSB</td><td>Protected specimen brushing</td></tr><tr><td>PUD</td><td>Peptic ulcer disease</td></tr><tr><td>PVAP</td><td>Possible ventilator-associated pneumonia</td></tr><tr><td>QAD</td><td>Qualifying antimicrobial day</td></tr><tr><td>RIT</td><td>Repeat Infection Timeframe</td></tr><tr><td>SCA</td><td>Specialty care area</td></tr><tr><td>SHEA</td><td>Society for Healthcare Epidemiology</td></tr><tr><td>SIR</td><td>Standardized infection ratio</td></tr><tr><td>SOT</td><td>Solid organ transplantation</td></tr><tr><td>SSI</td><td>Surgical site infection</td></tr><tr><td>SUR</td><td>Standardized utilization ratio</td></tr><tr><td>SUTI</td><td>Symptomatic urinary tract infection</td></tr><tr><td>URI</td><td>Upper respiratory tract infection</td></tr><tr><td>UTI</td><td>Urinary tract infection</td></tr><tr><td>VAC</td><td>Ventilator-associated condition</td></tr><tr><td>VAE</td><td>Ventilator-associated event</td></tr><tr><td>VAP</td><td>Ventilator-associated pneumonia</td></tr><tr><td>VRE</td><td>Vancomycin-resistant enterococci</td></tr><tr><td>WBC</td><td>White blood cell</td></tr><tr><td>WHO</td><td>World Health Organization</td></tr></table> MOH Surveillance Manual VII Last updated: November 2023 General Directorate of Infection Prevention and Control Introduction General Directorate of Infection Prevention and Control (GDIPC) at the Saudi Ministry of Health (MOH) manages all of hospitals in 20 regions of Saudi Arabia. Healthcare-associated infections (HAIs) are associated with significant morbidity and mortality. Additionally, they increase the length of stay in admitted patients and consequently the cost of healthcare services. Surveillance of healthcare-associated infections can provide the policy maker as well as healthcare providers with infections rates, a critical step in HAI prevention strategies. Vision GDIPC is committed to excellence and safety of healthcare services provided by the MOH hospitals across Saudi Arabia through promoting up to date infection practices including surveillance Mission GDIPC is committed to provide information that contribute to the delivery of the highest quality health care, by promoting safety and reducing the risk of acquiring and transmitting infections among patients, visitors, healthcare workers and supporting staff at MOH hospitals through ongoing data collection, consolidation, and analysis, followed by the dissemination of guiding information and actions, using sound epidemiological and statistical principles Target audience This manual was created to provide the necessary surveillance information for infection control professionals (ICP), epidemiologists, biostatisticians, and any other healthcare professional whose responsibilities include infection prevention at healthcare setting. MOH Surveillance Manual VIII Last updated: November 2023 Objectives This manual was created to provide the necessary surveillance information for the following objectives: - To measure the incidence of HAIs and organisms and establish their endemic rates by using standard definitions and methods to allow benchmarking local, regional, and international. - To investigate and control hospital clusters or outbreaks of HAI & resistant organisms among patients and personnel. - To maintain a comprehensive data system to monitor, evaluate, and implement the necessary actions to ensure a safe and healthy environment for patients, personnel, and visitors. - To monitor antimicrobial susceptibilities and the development of new resistant strains that may pose challenge to healthcare system. - To analyze temporal trends of aggregated data to ensure patient safety and appropriate allocation of available resources. • To evaluate new products to be used to control infection throughout the hospital. • To ensure compliance with national and international regulations. - To ensure compliance with the requirements of accrediting bodies, including Saudi Central Board for Accreditation of Healthcare Institutes (CBAHI) and international agencies such as the Joint Commission on Accreditation of Healthcare Organizations or the Rehabilitation Accreditation Commission. • To provide data and statistical analysis for research and publications. MOH Surveillance Manual IX Last updated: November 2023 Table of Contents Message from General Director...... IV Abbreviations....V General Directorate of Infection Prevention and Control .... VIII 1. Surveillance definition....1 2. Establishing a surveillance system....4 3. Surveillance methodology .... 11 4. Surveyor competencies....17 5. Requirements for HESN enrollment 21 6. Surveillance plan and risk assessment....24 7. Point prevalence survey 28 8. Surveillance location and duration....32 9. Healthcare-associated infection (HAI) 36 10. Infection pathogens 40 11. Surveillance of device-associated HAI 46 11.1 Central line associated bloodstream infection 50 11.2 Catheter-associated urinary tract infection 67 11.3 Ventilator-associated Event....75 11.4 Pediatric ventilator-associated event....91 11.5 Dialysis events 95 12. Surgical site infection....105 13. MDRO and CDI 124 14. Bundles 134 14.1 Central Line Insertion Bundle 135 14.2 Central line maintenance bundle 141 14.3 Adult ventilator bundle 143 14.4 Pediatric/neonatal ventilator bundle....148 14.5 Urinary catheter bundle 151 14.6 Surgical bundle....156 14.7 Dialysis bundle 160 15. Surveillance data collection....164 15.1 Numerator data 164 15.2 Denominator data....166 16. Infection control indicators....169 17. Evaluation of surveillance program 171 18. Surveillance data analysis 179 MOH Surveillance Manual X Last updated: November 2023 18.1 Basic statistics....180 18.2 Measures of morbidity and mortality....185 18.3 Calculating infection rates and ratios....188 18.4 Calculating SIR....191 18.5 Comparing rates....193 18.6 Data validation....197 18.7 Benchmarking ....201 19. Surveillance reporting....202 20. References....205 MOH Surveillance Manual XI Last updated: November 2023 1. Surveillance Definition Surveillance definition: Surveillance is a systematic method of ongoing collecting, consolidating, and analyzing data concerning the distribution and determinates of a given disease or event, followed by the dissemination of that information to those who can improve the outcome. Surveillance cycle: Surveillance cycle is not complete until data collection is translated into a report and recommendations for implementation as shown in the figure below. Difference between surveillance and clinical definitions: Surveillance and clinical definitions are different due to different purposes, as shown below: <table><tr><td></td><td>Clinical Criteria</td><td>Surveillance Criteria</td></tr><tr><td>Main aim</td><td>Aim to provide diagnosis and treatment for cared patients</td><td>Aim to provide trend for risk assessment, prevention, and policy change</td></tr><tr><td>Main focus</td><td>Focus on individual patients</td><td>Focus on a patient population</td></tr><tr><td>Allowance for clinical judgment</td><td>Clinical judgment is important</td><td>Clinical judgment is absent or minimal</td></tr></table> MOH Surveillance Manual 1 Last updated: November 2023 Objectives of HAI surveillance: Surveillance data can be used to serve several objectives: • To measure the incidence of healthcare associated infections (HAI) and organisms. • To establish endemic rates of HAI. • To early detect, investigate and control hospital outbreaks of HAI. • To monitor, evaluate, and implement the necessary preventive measures. • To work on reducing HAI using standard bundles. - To observe practices, such as hand hygiene and sterilizer performance monitoring, to promote compliance with recommendations and standards. • To monitor the occurrence of adverse outcomes to identify potential risk factors. - To prevent and control infections and occupational injuries in healthcare workers (HCWs). • To monitor antimicrobial susceptibilities. • To analyze temporal trends of aggregated data. • To evaluate new products to be used to control infection throughout the hospital. • To detect and report notifiable diseases to the Ministry of Health (MOH). - To identify organisms and diseases of epidemiological importance, such as antibiotic-resistant organisms and tuberculosis, to prevent their spread. • To ensure compliance with national and international regulations. - To ensure compliance with accrediting agency requirements, such as the Joint Commission on Accreditation of Healthcare Organizations or the Rehabilitation Accreditation Commission. - To provide information that can be used by responsible partners within/outside the health care facilities to target performance improvement activities. • To detect a bioterrorist event or an emerging infectious disease. - To provide data to conduct a facility risk assessment for diseases, such as legionellosis or tuberculosis. MOH Surveillance Manual 2 Last updated: November 2023 Effectiveness of surveillance: Surveillance without interventions can result in reduction of rates of infections simply due to change of the behaviors of healthcare providers. Surveillance would be most effective if the outcome met the following criteria: • Infections with high prevalence &/or incidence. • Infections associated with high morbidity &/or mortality. • Infections associated with long length of stay. • Infections associated with high treatment cost. • Preventable infections. Surveillance design: Surveillance design is unique and is different from survey and monitoring, as shown below <table><tr><td></td><td>Surveillance</td><td>Survey</td><td>Monitoring</td></tr><tr><td>Methods</td><td>Making repeated standardized surveys in order to detect possible changes</td><td>Making a single observation to measure and record health-related characteristics</td><td>Making repeated standardized measurements to detect unacceptable standards</td></tr><tr><td>Relation to time</td><td>Multiple points of time</td><td>One point of time</td><td>Multiple points of time</td></tr><tr><td>Relation to standards</td><td>Usually do not differentiate between acceptable and unacceptable standards</td><td>Not applicable</td><td>Usually have acceptable and unacceptable standards</td></tr><tr><td>Uses</td><td>HAI surveillance</td><td>Knowledge, attitude and practice (KAP) of hand hygiene in HAI prevention</td><td>Monitoring pressure in negative pressure isolation rooms</td></tr></table> MOH Surveillance Manual 3 Last updated: November 2023 2. Establishing a Surveillance System Establishing a surveillance system requires the following steps: 1. Assess the population and identify those at greatest risk for the outcome (e.g. blood stream infection) or process (e.g. central line insertion practices) of interest. 2. Select the appropriate outcome or process to be monitored by surveillance. 3. Select the appropriate surveillance methodology. 4. Create a surveillance manual. 5. Prepare surveillance resources. 6. Assemble surveillance team & engage stakeholders. 7. Train surveillance team. 8. Determine observation location. 9. Determine observation period. 10. Monitor for the outcome or process. 11. Stick to standardized definitions during monitoring. 12. Collect appropriate denominator data. 13. Create and maintain database. 14. Analyze surveillance data. 15. Report and use surveillance information in a timely manner. MOH Surveillance Manual 4 Last updated: November 2023 1. Assessing the population to survey: Assess the population and identify those at greatest risk for the outcome (e.g. blood stream infection) or process (e.g. central line insertion practices) of interest. Indicators that can be used to assess the population to survey: • What types of patients do we serve? • What are the most common diagnoses? • What are our most frequently performed surgical or other invasive procedures? - Which services or treatments are used most frequently? - Are there services or treatments that increase the risk of infection for the patient? • What types of patients increase liability and/or costs for the organization? • What types of patients with long length of stay in the organization? - Does the organization’s strategic plan focus on particular groups of patients? • What types of health concerns exist in the community, region, or regulatory environment? • Which patients are at increased risk for infection or other important outcomes? Sources of data required to assess the population to survey • Medical records. • Financial services. • Information services. • Quality/utilization management. - Surgical database. • Administrative/management reports. - Risk management. • Community agencies. • Occupational/employee health. • Human resources records. MOH Surveillance Manual 5 Last updated: November 2023 Vulnerable patient populations who are higher risk of infection - Elderly - Immunosuppressed - Organ or bone marrow transplant - HIV / AIDS - Pregnant women - Infants and children - Diabetics - Alcohol/substance users • Chronic obstructive pulmonary disease - Congestive heart failure - Other chronic illnesses - Dialysis 2. Selecting the appropriate outcome or process to be monitored by surveillance: Outcome versus process - Select the appropriate outcome or process to be monitored by surveillance. - Examples of outcomes: HAI, infection or colonization with a specific organism, pyrogenic reaction or vascular access infection in hemodialysis patients, sharps injuries, etc. - 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, personnel compliance with protocols, etc. - Examples of other events: Occurrence of reportable diseases and conditions, communicable diseases in personnel, organisms or syndromes indicative of bioterrorist events, etc. Selecting the outcome or process should be based on: • High prevalence &/or incidence. • High morbidity &/or mortality. - Long length of stay. • High treatment cost. - Preventable. - Satisfy customer needs / satisfaction. MOH Surveillance Manual 6 Last updated: November 2023 - Satisfy organizational mission / strategic goals. - Can be done with available resources. 3. Select Surveillance methodology: Routine HAI surveillance in most in-patient healthcare facilities should be conducted by ICP in: 1. An active 2. Patient-based 3. Prospective 4. Priority-directed manner 5. That yields risk-adjusted incidence rates 4. Create surveillance manual for: • Outcome & process - Methodology - Location and durations • Data collection forms • Data analysis methods - Benchmarking - Reporting 5. Prepare surveillance resources: - Office space - Computers • Information technology services • Administrative services • Media services - Folders, papers, pens, cabinets, storage media, pagers - Microsoft Office (Word, PowerPoint, and Excel) and statistical software MOH Surveillance Manual 7 Last updated: November 2023 6. Assemble surveillance team & engage stakeholders: • Hospital epidemiologist - ICP • Infection control coordinator • Data entry clerks - Biostatistician 7. Train surveillance team: • Start with recruiting qualified persons - All must be formally trained in infection prevention and control (IPC) to understand: √ Microbiology √ Sterilization/ disinfection √ Ward practice and risk Assessment √ Hospital design and management √ Surveillance and research methodology √ Short courses, training sessions, campaigns, conferences, diploma, CIC.... 8. Determine observation location: • Inpatient versus outpatient • Intensive care units versus wards • Regular wards versus specialty care areas • Unit-based versus hospital-based 9. Determine observation period: - It should be sufficient to collect sufficient data. It could be affected by the hospital resources, hospital size, target population, health care priorities ...etc. • The shortest unit time in surveillance is one month MOH Surveillance Manual 8 Last updated: November 2023 10. Monitor for the outcome or process: • Develop data collection tools for each surveillance initiative - Limit data collection to only what is needed for meeting the specific objective - Design forms considering flow of patient charts / data sources and ease of data recording / entry • Data collection include numerator and denominator data 11. Stick to standardized definitions during monitoring: - Use standardized written case definitions to ensure precise surveillance. - When available and applicable, use previously published, validated definitions - When historical data are used for internal comparisons or for external comparisons, ensure that the same definitions are used for outcomes and processes and that populations are at similar risk - If definitions are changed, be aware that such changes compromise the comparability of rates over time. 12. Collect appropriate denominator data: • Counts of the cohorts of patients at risk of acquiring HAI - For device-associated HAI incidence rates: record daily 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 - For SSI rates: record information on operative procedures selected for surveillance (e.g., type of procedure, date, risk factors, etc.) 13. Create and maintain database: • Type: Microsoft Excel, SPSS, other software - Separate for each surveillance component - Names and dates - Safety - Storage - Manuals MOH Surveillance Manual 9 Last updated: November 2023 14. Analyze surveillance data - Infection rates - Device utilization • Compliance rates of preventive bundles • Standardized infection ratio - Benchmarking 15. Report and use surveillance information in a timely manner • Quarterly reports versus annual reports - Consider audience - Consider stakeholders - Consider units where data were collected MOH Surveillance Manual 10 Last updated: November 2023 3. Surveillance Methodology The patient safety surveillance modules must use the following methodology: 1. Active surveillance 2. Patient-based surveillance 3. Prospective surveillance 4. Targeted surveillance 5. Yields risk-adjusted incidence rates - This means that the ICP shall seek out infections during a patient's stay by screening a variety of data sources. - Retrospective chart reviews should be used only when patients are discharged before all information can be gathered. - Other HCW (other than ICP) may be trained to screen data sources for these infections, but the ICP must make the final determination. - To minimize the ICP's data collection burden, others may be trained to collect the denominator data (separate forms for device/medication -associated infections). MOH Surveillance Manual 11 Last updated: November 2023 1. Active versus passive 1. Active surveillance - Trained personnel, mainly ICPs, vigorously look for HAI - Information accumulated by using a variety of data sources within and beyond the nursing ward 2. Passive surveillance - Persons who do not have a primary surveillance role, such as ward nurses or respiratory therapists, identify and report HAI - It is acceptable for denominator data <table><tr><td></td><td>Active Surveillance</td><td>Passive Surveillance</td></tr><tr><td>Person in charge</td><td>Data are collected by trained ICP as part of planned surveillance</td><td>Data are reported by non-trained personnel as per reporting regulations</td></tr><tr><td>Source of information</td><td>Attempt to search multiple data sources</td><td>No attempt to search multiple data sources</td></tr><tr><td>Time required</td><td>Needs more effort and time</td><td>Needs less effort and time</td></tr><tr><td>Missing data</td><td>Few missing events</td><td>More missing events</td></tr><tr><td>Example</td><td>ICP collect CLABSI numerator data</td><td>Staff nurse call ICP to report a pneumonia case</td></tr></table> MOH Surveillance Manual 12 Last updated: November 2023 2. Patient-based versus laboratory-based surveillance 1. Patient-based surveillance - Count HAI, assess risk factors, and monitor patient care procedures and practices for adherence to infection control principles - Requires ward rounds and discussion with caregivers 2. Laboratory-based surveillance - Detection is based solely on the findings of laboratory studies of clinical specimens <table><tr><td></td><td>Patient-based Surveillance</td><td>laboratory-based Surveillance</td></tr><tr><td>Case-finding</td><td>Data collected from multiple resources (e.g. visit patient care areas, review charts, & discuss with care giver)</td><td>Case-finding based solely on positive lab findings</td></tr><tr><td>Surveillance definition</td><td>Can verify standard surveillance definition</td><td>Usually can NOT verify standard surveillance definition</td></tr><tr><td>Uses</td><td>Can monitor events, risk factors, and practices</td><td>Can NOT monitor risk factors and practices</td></tr><tr><td>Example</td><td>Device-associate HAI and SSI surveillance</td><td>LabID event detection in the MDRO/CDI</td></tr></table> MOH Surveillance Manual 13 Last updated: November 2023 3. Prospective versus retrospective surveillance 1. Prospective surveillance • Monitor patients during their hospitalization - For SSIs, also monitor during the post-discharge period 2. Retrospective surveillance • Identify infections via chart reviews after patient discharge <table><tr><td></td><td>Prospective Surveillance</td><td>Retrospective Surveillance</td></tr><tr><td>Onset of data collection</td><td>Data collection starts before patient discharge</td><td>Data collection starts after patient discharge</td></tr><tr><td>Ascertainment bias</td><td>Less ascertainment bias</td><td>More ascertainment bias</td></tr><tr><td>Missing data</td><td>Few missing events as more resources are available</td><td>More missing events as less resources are available</td></tr><tr><td>Implementation</td><td>Easy to establish</td><td>May be difficult to establish</td></tr></table> MOH Surveillance Manual 14 Last updated: November 2023 4. Priority-directed versus comprehensive surveillance 1. Priority-directed (also called targeted or focused) surveillance - Objectives for surveillance are defined - Focus is on specific events, processes, organisms, and/or patient populations 2. Comprehensive surveillance - Continuous monitoring of all patients for all events and/or processes • Highly personnel resource intensive if done manually <table><tr><td></td><td>Targeted Surveillance</td><td>Comprehensive Surveillance</td></tr><tr><td>Focus</td><td>Focus on important HAI (e.g. device-associated), locations (e.g. ICUs), and population (e.g. dialysis patients)</td><td>Covers all HAIs in all hospital locations and populations</td></tr><tr><td>Weight of problems</td><td>Weight of problems is respected. Priority & objective directed</td><td>Equal weights for different problems</td></tr><tr><td>Annual risk assessment</td><td>Preceded by annual risk assessment and plan</td><td>No need for annual risk assessment and plan</td></tr><tr><td>Implementation</td><td>Usually feasible & less labor intensive</td><td>Usually unfeasible & more labor intensive</td></tr><tr><td>Effectiveness</td><td>More cost-effective</td><td>Less cost-effective</td></tr></table> MOH Surveillance Manual 15 Last updated: November 2023 5. Risk-adjusted rates versus crude rates surveillance 1. Risk-adjusted rates - Rates are controlled for variations in the distribution of major risk factors associated with an event's occurrence - Such rates allow inter- and intra-facility rate comparisons • Common methods used for risk-adjustment in HAI surveillance ○ Stratification by location in surveillance of device associated infections ○ Stratification by surgery type in SSI surveillance ○ Stratification by risk index category in SSI surveillance ○ Stratification by birth weight group in neonatal CLABSI and PedVAE ○ Stratification by type of central line in CLABSI in specialty care areas ○ Stratification by vascular access in dialysis event in dialysis centres ○ Standardized infection ratio 2. Crude rates - Rates assume equal distribution of risk factors for all events - Such rates cannot be used for inter-facility comparisons <table><tr><td></td><td>Adjusted rates</td><td>Crude rate</td></tr><tr><td>Risk factor assumptions</td><td>Rates are controlled for variations in the distribution of major risk factor associated with an event's occurrence</td><td>Rates assume equal distribution of risk factors for all events</td></tr><tr><td>Credibility</td><td>Useful for benchmarking</td><td>Benchmarking may be misleading</td></tr><tr><td>Example</td><td>SIR for SSI for patients in surgical ward</td><td>SSI rates in all patients in surgical ward</td></tr></table> MOH Surveillance Manual 16 Last updated: November 2023 4. Surveyor Competencies Competency definition (APIC): Observable and measurable knowledge, skills, abilities, and personal attributes that improve performance and result in success (doi: 10.1016/j.ajic.2012.03.002) Updated APIC Competency Model for the ICP 1. Leadership 2. IPC informatics 3. Quality improvement 4. IPC operations 5. Research 6. Professional stewardship 1. Leadership - Communication: The ability to influence, serve as a role model, demonstrate accountability and integrity, and communicate the value of infection prevention to a diverse audience to achieve desired outcomes are all required for leadership competency. - Critical thinking skills: Critical thinking means seeking and using all information to examine a problem or situation and finding solutions through creative application of knowledge, experience, data, and evidence. - Collaboration: ICP's work is executed effectively and sustainably only through working with multiple departments and disciplines to carry out the IPC program's goals. - Behavioral science: Familiarity with psychology and socio-adaptive strategies become valuable because prevention efforts in large part can be behaviorally focused, requiring collaboration, engagement, and communication. - Program management: ICPs also need to be effective and efficient managers of budgets, resources, personnel, and programs. - Mentorship: Effective and timely mentorship can play a critical role in the success of ICPs, especially those new to the profession, because ICPs come to IPC from varied backgrounds from within nursing and non-clinical fields and have not shared standardized training. MOH Surveillance Manual 17 Last updated: November 2023 2. IPC informatics • Surveillance Technology • Electronic Medical Record (EMR) • Data management, analysis, and visualization • Applications of novel diagnostic technologies 3. Quality improvement • ICPs as subject matter experts • Engaged in performance improvement processes • Engaged in overall patient safety program • Data utilization to aid in decision-making and goal setting • Risk assessment and risk reduction 4. IPC operations • Epidemiology and surveillance - Education - IPC rounds • Cleaning, disinfection, and sterilization • Outbreak management • Emerging technologies • Antimicrobial stewardship • Diagnostic stewardship 5. Research - Evaluation of research • Comparative effectiveness research - Implementation and dissemination science - Conduct or participate in research and evidence-based practices. 6. Professional stewardship - Ensure that accountability measures are in place - Ethics - Ability to quantify the costs and savings of IPC initiatives MOH Surveillance Manual 18 Last updated: November 2023 • Population health and community infections • The continuum of care • Advocacy and role model Stages of Competency 1. Novice 2. Becoming proficient 3. Proficient 4. Expert 1. Novice ICP - The Novice ICP has very limited knowledge, skills, experience, and basis in which to have situational awareness in IPC and epidemiology. - The Novice must rely on rules and concepts to guide their practice and begin to develop their knowledge/skills in the core competencies. 2. Becoming Proficient ICP - ICP continues to build on their knowledge/skills in the core competencies while developing into an independent practitioner. - He/she is able to briefly move beyond rule-based thinking to identify common trends that need to be addressed to ensure patient safety. 3. Proficient ICP - The CIC indicates that the ICP has knowledge required for competent performance in IPC. - ICP begins to apply the core competencies independently and deepens their knowledge and application of the future-oriented competency domains. 4. Expert ICP - The Expert ICP shares their knowledge and skills through mentoring, research, publication, collaboration, leadership, and educating other ICPs. MOH Surveillance Manual 19 Last updated: November 2023 CIC Credential • CBIC core competencies are evidence-based, reflective of current practice - ICPs renew and enhance their skills and application of the core competencies throughout their careers. CIC core competencies • Identification of infectious disease processes • Surveillance and epidemiologic investigations • Preventing/controlling the transmission of infectious agents • Employee/occupational health • Management and communication (leadership) • Education and research MOH Surveillance Manual 20 Last updated: November 2023 5. Requirements for HESN Plus Enrollment Health Electronic Surveillance Network (HESN) Plus Program: It is an integrated national electronic surveillance system that has several domains to uniformly monitor communicable diseases, disease epidemics, immunization, and HAIs across Saudi Arabia. It allows users at different hospitals to continually and uniformly report HAIs to the GDIPC at Riyadh, Saudi Arabia. Requirements for HESN Plus Enrollment: Each hospital is eligible for participate in HESN Plus HAIs surveillance plan if the following criteria are met: - Availability of microbiology laboratory or has signed documented agreement with external or referral laboratory. • Availability of dedicated surveillance coordinator • Availability of internet services and adequate number of personal computers • For device-associated infections: √ The hospital should have at least one critical care unit (ICUs, CCU, NICU, etc.) • For surgical site infections: √ The hospital should have a standard operating room (OR) and undergoing at least one recognized surgery. - For dialysis event: √ The hospital should have a dialysis center or unit serving hemodialysis outpatients √ Units serving only inpatients do not meet the criteria MOH Surveillance Manual 21 Last updated: November 2023 Enrollment Application: If the above criteria are met, the hospital should fill an enrollment application submitted through HESN Plus program and approved by the GDIPC surveillance department. The application is filled electronically and includes the following information: - Region - Hospital name • Total bed capacity • How many critical care units and how many beds in each one - Surgical procedures chosen for SSI surveillance according to the protocol - Name of the surveillance coordinators in the hospital and their contacts • Other required information Creation of HESN Plus users: Infection Control Unit Roles in HESN Plus 1. HESN Plus Infection Control User: Is the employee who works in the healthcare facility and enters the Surveillance information 2. System Manager for a Medical Facility: Is the system administrator at the level of their medical facility 3. Directorate: Is the administrative director of the directorate they are in charge of, and is able to access all data of the medical facilities that fall under their directorate. 4. System Administrator: Is the system administrator for Infection Control and can access data of all medical directorates and facilities. Submitting a Request to the Infection Control Unit No facility can use the Infection Control Unit without first submitting a request through HESN+ and having it approved by the Infection Control Unit Administration. The application process is as follows: 1. Click on the Infection Control Unit icon and then on the “Submit Request” button MOH Surveillance Manual 22 Last updated: November 2023 2. The concerned facility fills in the facility's details on Intensive Care Units (ICUs), Procedures, and Infection Control Administration, and then submits the application. After submitting the application, it will be sent to the Infection Control Administration at the Ministry of Health for review. Reviewing a Facility's Request The system administrator user of the Infection Control Unit can view the requests of health facilities submitted through the requests page, and by clicking on the request number, they can preview the facility's request details. Returning a Request The system administrator can return a request to the healthcare facility to complete or correct some data as deemed appropriate, in accordance with the standards of the Infection Control Unit. This can be done by clicking the “Return Request” button and adding notes on the edits required to be made by the healthcare facility. Rejecting a Request The system administrator can reject the request of a healthcare facility, as deemed appropriate, in accordance with the standards of the Infection Control Administration. This can be done by clicking the “Reject Request” button and adding notes on the rejection of the request. Approve a Request The system administrator can approve the request of the healthcare facility, as deemed appropriate, in accordance with the standards of the Infection Control Administration. After approving the request, the healthcare facility will be immediately able to use the Infection Control Unit on the HESN+ platform. MOH Surveillance Manual 23 Last updated: November 2023 6. Surveillance Plan and Risk Assessment Infection Control Risk Assessment: Infection control risk assessment is a coordinated activity to identify the risks for acquiring and transmitting infections based on the patient population served, the types of services provided, and the analysis of surveillance data Purpose of infection control risk assessment: 1. Evaluation of potential risk for infections, contamination and exposures - Based on known risk, historical data and reports in literature 2. Evaluation of harm - Life threatening, loss of function, loss of community trust, loss of organization good will, financial threat, legal and/or regulatory issues 3. Evaluation of organization's preparedness • To eliminate or mitigate the harm or risk of harm Components of infection control risk assessment: 1. Probability of occurrence of the event/condition: based on known risks, historical data & reports in literature <table><tr><td>Rate</td><td>Probability of occurrence</td><td>Description</td></tr><tr><td>0</td><td>Never</td><td>No possibility to occur</td></tr><tr><td>1</td><td>Rare</td><td>Risk is not expected to occur</td></tr><tr><td>2</td><td>Maybe</td><td>Occur infrequently but remain a possibility, few times per year or per activity</td></tr><tr><td>3</td><td>Likely</td><td>Risk is not a persistent issue, once several times per year month or per activity</td></tr><tr><td>4</td><td>Expected</td><td>Occur frequently, pose a constant threat once or several times per day</td></tr></table> MOH Surveillance Manual 24 Last updated: November 2023 2. Impact of the event/condition at different levels • Threat to life and or health • Disruption of services - Loss of function • Prolonged length of stay • Financial impact - Legal issues • Regulatory/accrediting/organizational issues <table><tr><td>Rate</td><td>Consequence of occurrence</td><td>Description</td></tr><tr><td>1</td><td>Minimal clinical</td><td>No real risk or harm</td></tr><tr><td>2</td><td>Moderate clinical</td><td>Minimal real risk or harm</td></tr><tr><td>3</td><td>Permanent harm</td><td>Prolonged length of stay</td></tr><tr><td>4</td><td>Serious Loss</td><td>Permanent injury</td></tr><tr><td>5</td><td>Life threatening</td><td>May cause death</td></tr></table> MOH Surveillance Manual 25 Last updated: November 2023 3. Current preparedness of the system • Status of current plans and implementation - Training status • Availability of backup systems • Community/Public Health resources <table><tr><td>Rate</td><td>Preparedness level</td><td>Description</td></tr><tr><td>1</td><td>Solid</td><td>Risk would be avoided if plan of actions took place</td></tr><tr><td>2</td><td>Good</td><td>Consequences are minimized by the plan of actions</td></tr><tr><td>3</td><td>Fair</td><td>Plan of actions needs to be modified ASAP</td></tr><tr><td>4</td><td>Poor</td><td>Plan of action not enough</td></tr><tr><td>5</td><td>None</td><td>No plan of Action</td></tr></table> MOH Surveillance Manual 26 Last updated: November 2023 Example of infection control risk assessment: <table><tr><td>Event or Condition</td><td colspan="5">What is probability of event/condition occurring?</td><td colspan="5">What is potential impact of event/condition on patients and staff?</td><td colspan="5">What is organization's preparedness to deal with this event/condition?</td><td>Numerical risk level</td></tr><tr><td>Level</td><td>Expected</td><td>Exactly</td><td>Likely</td><td>Maybe</td><td>Rare</td><td>Never</td><td>Little threatening</td><td>Serious Loss</td><td>Premature harm</td><td>Moderate clinical</td><td>Minimal clinical</td><td>None</td><td>Poor</td><td>Fair</td><td>Good</td><td>Solid</td><td>Total</td></tr><tr><td></td><td>4</td><td>3</td><td>2</td><td>1</td><td>0</td><td>5</td><td>4</td><td>3</td><td>2</td><td>1</td><td>5</td><td>4</td><td>3</td><td>2</td><td>1</td><td></td><td></td></tr><tr><td>C-diff infection</td><td>4</td><td></td><td></td><td></td><td></td><td></td><td></td><td>3</td><td></td><td></td><td></td><td></td><td>3</td><td></td><td></td><td></td><td>36</td></tr><tr><td>CABG SSI</td><td>4</td><td></td><td></td><td></td><td></td><td></td><td>4</td><td></td><td></td><td></td><td></td><td>4</td><td></td><td></td><td></td><td></td><td>64</td></tr></table> - Multiply the ratings for each risk in the area of probability, impact and current systems • C-diff infection risk: \( 4 \times 3 \times 3 = 36 \) • CABG SSI risk: \( 4 \times 4 \times 4 = 64 \) - Sort the total score in descending order • Determine a cut off value below which no action is necessary - Review with organization for acceptance of priorities MOH Surveillance Manual 27 Last updated: November 2023 7. Point Prevalence Survey Point Prevalence Survey (PPS) of HAIs: - PPS is a count of the number of patients with a particular condition (in this case a HAIs) at a particular time (in this case one day), as a proportion of the total number of patients who are hospitalized at that particular time. - PPS only counts the condition if present at the time (on the day) of the survey, but does not count if it is present at other times during the patient stay in the hospital. Objectives of PPS: • To estimate the overall burden of HAIs - To describe specific types of HAIs and their causative organisms and associated antimicrobial use - To set priorities for future surveillance as regards types of HAIs and the units surveyed • To increase the surveillance skills of ICPs - Publications Duration/date of PPS: - One day - Choose a day with no much staff leaves - Avoid days with more scheduled procedures/admissions than usual MOH Surveillance Manual 28 Last updated: November 2023 Steps of PPS: 1. Creating data collection form 2. Training of ICPs on PPS methodology 3. Training of ICPs on HAI definitions 4. Data collection during the day of the PPS and afterwards if needed 5. Data validation by reviewing positive cases with ID physicians 6. Data entry of validated cases 7. Analysis and report writing Patients' selection criteria in PPS: - Inpatients of any age are eligible for inclusion as long as he/she is admitted to the ward/unit before or at 8 a.m. and not discharged from the ward at the time of the survey - Patients in outpatient clinics, emergency departments (<1 day), same day surgery, and outpatient dialysis patients are excluded Outcome of PPS: • The outcome is active HAI infections - HAI infections: Infections that met the surveillance definition criteria of the National Healthcare Safety Network (NHSN), with onset ≥3 days from admission • Active infections: Infections that met NHSN surveillance definition criteria, with √ Signs or symptoms of infection present on the survey date or √ Antimicrobial therapy for an HAI is still being given on the survey date - Note that all types of HAI infections should be included not only the ones that we regularly do surveillance for as CLABSI or CAUTI MOH Surveillance Manual 29 Last updated: November 2023 Types of HAIs included in PPS: <table><tr><td colspan="4">□ Pneumonia□ PVAP of VAE □ Other HAI pneumonia</td></tr><tr><td colspan="4">□ Blood stream infection□ CLABSI □ Secondary BSI □ Dialysis □ Others</td></tr><tr><td colspan="4">□ Urinary tract infection□ CAUTI □ Others</td></tr><tr><td colspan="4">□ Surgical site infection□ Superficial □ Deep □ Organ Surgery: ......</td></tr><tr><td colspan="4">□ Lower respiratory system infection, other than pneumonia: ......</td></tr><tr><td colspan="4">□ Gastrointestinal system infection□ Clostridium difficile Infection □ Intra-abdominal infection □ ......</td></tr><tr><td colspan="4">□ Skin and soft tissue infection□ Burn □ Decubitus ulcer □ Skin/wound □ Breast □ ......</td></tr><tr><td colspan="4">□ Reproductive tract infection: ......</td></tr><tr><td colspan="4">□ Bone and joint infection: ......</td></tr><tr><td colspan="4">□ Central nervous system infection: ......</td></tr><tr><td colspan="4">□ Cardiovascular system infection: ......</td></tr><tr><td colspan="4">□ Upper respiratory tract infection (URI): ......</td></tr><tr><td colspan="4">□ Eye, ENT, or mouth infection other than URI: ......</td></tr><tr><td colspan="4">□ Others: ......</td></tr></table> MOH Surveillance Manual 30 Last updated: November 2023 Exceptions of the ≥3 days rule in HAI: - Onset ≤2 days BUT the patient was readmitted after discharge within the last 2 days - Onset ≤2 days BUT the patient was transferred from another hospital - Onset ≤2 days BUT the patient has Clostridium difficile infection where specimen was collected within 4 weeks from last discharge (community-onset healthcare-associated CDI) - Onset ≤2 days BUT the patient has surgical site infection occurring after 30/90 days from a relevant surgery Recurrent HAIs in PPS: • They are collected in PPS as long as meeting the definition of active infection Missing data at the date of PPS: • We should not go prospectively after them - Results of tests/examinations that are not yet available on the survey date should neither be completed after the survey date nor taken into account when establishing whether the case definition criteria are fulfilled. - This will probably cause some actual cases of HAI to be discarded, but this can be seen as compensation for the (potentially long) retrospective period preceding the start of the treatment when no more signs or symptoms are present on the survey date. MOH Surveillance Manual 31 Last updated: November 2023 8. Surveillance Location and Duration Surveillance is planned based on location and duration Types of patient care hospital locations I- 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 (ICU): A care area that provides intensive observation, diagnosis, and therapeutic procedures for adults (Adult ICU), children (Pediatric ICU, PICU), or neonates (Neonatal ICU, NICU) who are critically ill. The critical care could be surgical, medical, trauma, respiratory, neurologic...etc. Care areas that provide step-down, intermediate care or telemetry are not considered ICU. 2. Specialty care area (SCA): Hospital location which includes one of the following units: Bone marrow transplant, solid organ transplant, inpatient acute dialysis, hematology/oncology. 3. Other inpatient: including any inpatient locations which is not ICU or SCA e.g. inpatient medical, surgical, step down units, and OR. The later may include an operating room, C-Section room, interventional radiology room or a cardiac catheterization lab, or post-anesthesia care unit. II- Outpatient locations: Locations serving 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, Outpatient Emergency Department, or same day surgery and its 24-hour observation area Non-patient care locations • Community locations: e.g. Home care • Non-patient care hospital locations: e.g. Laboratory or laundry. MOH Surveillance Manual 32 Last updated: November 2023 Location is mapped according to acuity level and type of service 80% rule for determining the acuity level of the unit - The acuity level of unit is determined by the type of care served in that unit. - That is, if at least 80% of patients are of the same acuity level (for example 80% acute care and 20% non-acute care), that unit is mapped as that acuity level (for example acute care unit). The choice will be based on the list of acuity levels of hospital locations (shown below) - If the 80% rule does not hold, try splitting the unit into 2 virtual locations. The use of virtual locations is recommended only for units that are geographically split by patient service or those in which beds are designated by service (for example neurology patients are housed in beds 1 thru 10 and the neurosurgery patients are housed in beds 11 thru 20). - If the 80% rule and virtual locations do not hold, map the unit as mixed acuity unit (comprised of patients with varying levels of acuity) List of acuity levels of hospital locations: • Adult critical care units • Pediatric critical care units • Neonatal critical care units • Specialty care areas (SCA)/oncology - Adult wards - Pediatric wards - Neonatal wards - Step down units - Mixed acuity units - Operating rooms - Chronic care - Long term acute care - Rehabilitation • Outpatient (acute) locations • Clinic (non-acute) settings MOH Surveillance Manual 33 Last updated: November 2023 Operating Rooms (OR) - OR: A patient care area that meets the American Institute of Architects (AIA) criteria for an operating room. This may include an operating room, C-Section room, interventional radiology room, or a cardiac catheterization lab. • Could be inpatient or outpatient 80% rule for determining the type of unit - The type of unit is determined by the kind of patients cared for in that unit. - That is, if at least 80% of patients are of a certain type (for example patients with trauma), that unit is mapped as that type of these patients (for example trauma ICU). - If the 80% rule does not hold, try splitting the unit into 2 virtual locations. The use of virtual locations is recommended only for units that are geographically split by patient service or those in which beds are designated by service (for example neurology patients are housed in beds 1 thru 10 and the neurosurgery patients are housed in beds 11 thru 20). - If the \(80\%\) rule and virtual locations do not hold, you have two scenarios: √ When a unit houses roughly equal populations (for example 50/50 or 60/40 of medical and surgical patients), that unit is mapped as combined patient unit (for example medical/ surgical ICU). √ When a unit houses mixed populations but one of them >60% (for example 70% medical and 30% surgical), that unit is mapped as that type of the patient majority (for example medical ICU). MOH Surveillance Manual 34 Last updated: November 2023 Surveillance location in different types of surveillance <table><tr><td rowspan="3"></td><td colspan="6">Locations</td></tr><tr><td colspan="5">Inpatients</td><td rowspan="2">Out-patients</td></tr><tr><td>Adult ICU</td><td>Pediatric ICU</td><td>Neonatal ICU</td><td>SCA</td><td>Other wards</td></tr><tr><td>CLABSI & bundle</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>VAE & bundle</td><td>VAE</td><td>Ped-VAE</td><td>Ped-VAE</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>CAUTI & bundle</td><td>Yes</td><td>Yes</td><td>No</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>DE & bundle</td><td colspan="5">No</td><td>Yes</td></tr><tr><td>SSI & bundle</td><td colspan="5">Yes</td><td>Yes</td></tr><tr><td>MDRO & bundle</td><td colspan="4">Yes</td><td>Yes</td><td>Yes</td></tr></table> Surveillance duration: - The least time period to do surveillance is one month (to allow for denominator collection) - Usually one quarter (3 months) are enough to give evidence about the rates of infection - In bigger units shorter duration can be tried and in smaller units longer duration can be tried MOH Surveillance Manual 35 Last updated: November 2023 9. Healthcare-Associated Infection (HAI) Infection definition: - The successful transmission of a microorganism to the host with subsequent multiplication, colonization, and invasion. - Infection may be clinical or subclinical and may not produce identifiable disease. - However, it is usually accompanied by measurable host response(s), either through the appearance of specific antibodies or through cell-mediated reaction(s) (e.g., positive tuberculin test results). Colonization definition: - The multiplication of a microorganism at a body site or sites without any overt clinical expression or detected immune reaction in the host at the time that the microorganism is isolated. • Colonization may or may not be a precursor of infection. • Colonization may be a form of carriage and is a potential source of transmission. Timelines for Infection and Disease <table><tr><td>Infection status</td><td>Latent period: time interval from exposure to infection to infectiousness</td><td>Infectious period: time during which the host is infectious</td></tr><tr><td>Disease status</td><td>Incubation period: time from exposure to infection to the development of symptomatic disease</td><td>Symptomatic period: period in which symptoms of the disease are present.</td></tr></table> MOH Surveillance Manual 36 Last updated: November 2023 Mode of transmission of infection: - It is the method of transfer by which the organism moves from host to susceptible individual • Transmission could be direct or indirect 1- Direct transmission (person-to-person): - Droplet contact: coughing or sneezing (1 meter) - Direct physical contact to infected person secretions, blood, stool/urine (This method includes sexual contact) • Trans-placental infection 2- Indirect transmission (person-environment-person): - Airborne transmission - if the microorganism can remain in the air for long periods (TB, varicella, measles) - Indirect contact - usually by touching soil contamination or a contaminated surface • Fecal-oral transmission - usually from contaminated food or water sources • Vector borne transmission - carried by insects or other animals - Inoculation (devices) MOH Surveillance Manual 37 Last updated: November 2023 HAI definition: - A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) - Not present or incubating on admission to the facility - An infection is considered HAI if the date of event of the NHSN site-specific infection criterion occurs on or after the 3rd calendar day of admission to an inpati …(230,663 more chars)