Introduction
91. As indicated earlier in this report, in the context of Designed to Care13 surveillance should be regarded as a quality issue in terms of clinical governance.
92. The major advantage offered by a national system of surveillance will be the opportunity for local results to be viewed in a wider context, with scope for true benchmarking and sharing of best practice in terms of HAI control. Additionally, it should act as an early warning system to alert local managers to emerging problems.
Recommendations:
Surveillance
93. A national framework for HAI surveillance should be established for the NHSiS. This framework should be developed by the Scottish Centre for Infection and Environmental Health (SCIEH), in conjunction with the NHS Management Executive and the professions, us *in , this report as a basis for discussion and should include agreed, precise definitions to be adhered to by all participants in the surveillance system. The framework should take account of developments in England and Wales in order to allow for direct comparison of data, wherever possible.
94. As an interim arrangement, in advance of the establishment of a national system of HAI surveillance, Health Improvement Programmes (HIPs) and Trust Implementation Plans (TIPs) should give explicit consideration to the problem of HAI, consistent with the need to protect and promote health.
95. In due course, Health Boards and Trusts should put in place locally agreed review arrangements to ensure that the monitoring information produced by SCIEH is acted upon.
96. Continuous surveillance should be encouraged in respect of specific areas such as surgical wound infections, device-related infections, pace-maker infections and IV cannulae and should be assessed against established criteria.
97. Targeted surveillance should be focussed on a limited number of common procedures, including day case procedures, in the first instance.
98. It is suggested that initial surveillance projects might usefully focus on auditing the incidence of HAI following elective Caesarian section and inguinal hernia repair. Regardless of the areas chosen, the Group recommends that they should be piloted to ensure feasibility and robustness of methodology before being adopted nationally.
99. CRAG is currently funding a national audit of morbidity and recurrence rate following hernia repair 34. There is therefore an opportunity to build on this existing audit in the future to include HAI surveillance data. The Group recommends that CRAG give serious consideration to funding such a project.
100. Future topics for HAI surveillance might include:
Post-Discharge Surveillance:
101. At present there is no standard method for undertaking surveillance outside of hospital 35 A number of different approaches have been adopted to date. These range from the census approach, in which each patient is surveyed for a set time period during the post-discharge recovery phase, to telephone surveys and questionnaires36-38. Despite the use of verbal or printed instructions, Seamann and Lammers 39 have found that patients are frequently unable to recognise signs of infection. These authors conclude that "reliance on printed instructions, telephone interviews, or any other means of patient self-evaluation may not allow early recognition of infection" and should not be used for post-discharge surveillance. With the formation of Local Health Care Co-operatives (LHCCs) and Primary Care Trusts (PCTs), signalled in Designed to Care13 , there may well be improved opportunities for monitoring this difficult area in the future. The Group therefore recommends that SCIEH should establish links with all Scottish Trusts, including PCTs, to develop mechanisms for the accurate measurement of HAI post-discharge as part of the national surveillance system.
Other Recommendations:
Use of Specialist Nurses in HAI Surveillance
102. In the Trust setting., nurses who manage invasive devices, such as urinary catheters, intravascular cannulae, epidural cannulae and nasogastric tubes, are in an ideal position to identify early signs of infection. Similarly, specialist nurses -such as those involved in breast care, day surgery and the care of patients on TPN etc.- are well placed to contribute to HAI surveillance in their respective patient groups. In addition, many such nurses have ongoing responsibility for their patients post-discharge and are therefore ideally situated to collect data on HAI in the community. Health Visitors could also be utilised in this way. The Group recommends that Health Service Managers should give consideration to the optimal deployment of these existing resources for the purposes of reducing HAI.
Use of Clinical Audit in HAI Surveillance
103. The scientific basis for claims of efficacy of HAI surveillance and control programmes has already been established by the Study of the Efficacy of Nosocomial Infection Control (SENIC) Project 6 (see also paragraph 3). A planned programme of audit formed a key component of this study which involved over 300 hospitals in the US during the 1970s. The study demonstrated that, overall, 32% of HAI involving the four major sites (bloodstream, surgical wound, urinary tract and respiratory tract) could be prevented with high intensity infection surveillance and control programmes. By contrast, the same study showed that hospitals with an infection programme but no form of surveillance only succeeded in reducing infection by an average of 6%. Hospitals without any form of infection control saw rates of infection rise by as much as 18%. Subsequent studies have demonstarted that HAI surveillance is not only clinically effective but also cost-effective40-41. No corresponding studies have been mounted in the UK but, given the outcomes of the SENIC study, it seems more than likely that good infection control plus selective surveillance and early feedback of results to clinicians has the potential to reduce the rate of infection and associated costs in the NHSiS.
104. As indicated in Designed to Care13 , clinical audit is an essential component of clinical effectiveness, which in turn is fundamental to the process of clinical governance. Clinical audit should no longer be considered in isolation, but form an integral part of every organisation-'s clinical governance programme.
105. Experience has shown that medical case records or abstracts perform poorly when attempting to find cases of nosocomial infections42. To make clinical surveillance meaningful, it will be necessary to collect accurate data on patient risk factors and demographics.
106. Demonstrating the value of surveillance data to all interested parties is essential. The audit tool can be used to evaluate the true impact not only of the dissemination of surveillance data but also the process of infection control. Audit is conventionally represented as a cycle and its principles are familiar to most health care professionals. This process can be applied to any aspect of a surveillance programme or antibiotic prescribing policy43.
107. The Consensus Statement to Prevent and Control the Emergence and Spread of Antimicrobial Resistant Micro-organisms in Hospital 1 includes a number of process and outcome indicators which could be used to evaluate an organisation's progress towards achieving its infection control goals. For example, these indicators could include an investigation of the organisation of surveillance and resource utilisation, an evaluation of patient inclusion and a check on the quality of data used 44 . This can often be done by an independent reviewer and is necessary to ensure that surveillance networks are appropriate and reliable and produce the desired outcomes. Examples of simple targets for surveillance audit could include optimising the timing and duration of surgical antibiotic prophylaxis or reducing surgical wound infection. Successive audits of the latter are capable of bringing about a remarkable reduction in infection rate45.
108. Against this background, the Group recommends that clinical audit should be an integral part of the proposed national framework for HAI surveillance in Scotland.
Use of Electronic Linkage between Laboratories and Public Health Agencies
109. Designed to Care13 commits the NHSiS to the increased use of electronic communications, including the NHSnet. Ministerial approval has already been given to complete the infrastructure between Health Boards, Acute Trusts and Primary Care Trusts and links will also be possible to Environmental Health Officers through secure mail services. SCIEH currently have a Project Board charged with responsibility for taking forward the Pennington Report` recommendation on electronic transmission between NHS microbiology laboratories and SCIEH.
110. The Group recommends that this Project Board takes forward the development of a minimum core dataset to streamline the capture and exchange of HAI surveillance data from laboratories to Health Boards and SCIEH using the NHSnet.
111. In the event of an outbreak, extra information could be collected by Health Boards, supplementary to routine minimum data. Access to anonymised, aggregated data held by SCIEH would be provided to authorised staff within the NHSiS. Use of standard definitions and automated reporting should result in improved data quality and will also mean that anonymised data should be easily accessible for research and management purposes through the NHSnet.
Antimicrobial Resistance
112. There is considerable national and international concern surrounding the associated issues of increasing antimicrobial resistance and antimicrobial prescribing patterns, as highlighted in the House of Lords Select Committee report 11. The Standing Medical Advisory Committee has produced guidance in this area which has been circulated widely throughout the NHS12. A recent major EU Conference, held at the instigation of European Chief Medical Officers and hosted by the Danish Government, also considered these issues in depth and recommended that a European surveillance system should be established for antimicrobial resistance.
113. The Group therefore recommends that the Project Board (referred to in paragraph 109) should also begin to examine the feasibility of linking HAI surveillance data collection to antimicrobial resistance patterns and prescribing data in Trusts and the Community, as recommended in the House of Lords Select Committee report 11 and reinforced at the recent EU Conference.
Conclusion
114. The Group acknowledges that implementation of this report's recommendations cannot be cost neutral. However, it believes that the case for additional funding for improved HAI surveillance in the NHSiS has been made, and that future cost savings may result. The Group therefore recommends that the Management Executive give serious consideration to the funding of any business case(s) submitted by SCIEH as a result of the above recommendations.