Page 18 - policy and procedure infection control

Policies and Procedures on Infection Control

2. HEALTHCARE ASSOCIATED INFECTION
SURVEILLANCE

2.1 Introduction

Surveillance is one of the most important components of an effective infection control
program. It is defined as the systematic collection, analysis, interpretation, and
dissemination of data about the occurrence of HCAIs in a definite patient population.

2.2 Purpose of Surveillance
1. To established and main a database describing endemic rates of HCAIs. Once
endemic rates are known then the occurrence of an epidemic can be detected when
infection rates exceed baseline values.
2. To identify trends manifested over a finite period, such as shifts in microbial pathogen
spectrum, infection rates, etc.
3. To provide continuous observation of HCAIs cases for the purpose of prevention and
control.
4. To obtain useful information for establishing priorities for infection control activities.
5. To quantitatively evaluate control measures effectiveness for a definite hospital
population.

6. To enhance the role and authority of the infection control team in the hospital through
participation in ward rounds, consultations and education of healthcare workers.

2.3 Main components of Surveillance system
1. Definition of HCAI

Infections that occur more than 48 hours after admission (It must be taken into
account that different infections have different incubation periods, so that each
occurrence must be evaluated individually to determine the relationship between its
occurrence and hospitalization).
2. Case Definition
Each case definition must be standardized and consistent. The case definition used
nationwide will be that of CDC definitions. (Refer to Appendix A for ‘Definitions of
HCAI’ developed by CDC.)
i. Daily review of all positive culture results
(Manually / Lab information system / Automated disc reader)

ii. Informed by infection control link nurse when diagnosed by clinician.
iii. Identified during ward rounds / antibiotic rounds / Infectious disease rounds / ICU rounds.
iv. Actively looking for cases in targeted surveillance and follow–up these cases.

Ministry of Health Malaysia 7