Promotion of Quality and Safety of Healthcare in Egypt by Implementing a Pilot Surveillance Program for Hospital-acquired infections
Developing countries have high rates of hospital-acquired infections (HAIs) due to an increase of invasive medical devices and procedures in intensive care units (ICUs) without the necessary infection control measures. Surveillance programs for HAIs or antimicrobial resistance (AMR) did not exist in Egypt prior to an interagency agreement between the US Naval Medical Research Unit No.3 (NAMRU-3) in Cairo and the United States Agency for International Development (USAID) in Egypt. USAID provided funds through the IAA in June 2010; in June 2011 a surveillance project examining HAI and AMR began in 11 hospitals in Egypt, including 43 intensive care units (ICUs) representing both the Ministry of Health and University Hospitals. The surveillance project objectives included the following: 1) develop benchmarks for hospital infections, 2) identify the antimicrobial profile of pathogens causing hospital infections, 3) develop targeted prevention activities to decrease rates of infection, and 4) increase the capacities of infection prevention and control programs in hospitals. The first phase of the surveillance program took place from June 2011 until January 2012.
A surveillance strategy was developed by the Infection Control Unit at NAMRU-3, in collaboration with the U.S. Centers of Disease Control and Prevention (CDC), which focused on active prospective surveillance in all 43 ICUs in 11 participating hospitals. All types of HAIs (43) were subject to evaluation and standardized CDC case definitions were used. Personal Digital Assistants (PDAs) were used for data collection of hospital infections. This project provided the first documented use of PDA’s for HAI surveillance in the world. Intensive training was provided to hospital surveillance coordinators (n=122), ICU physicians (n=234), Infection Prevention & Control (IPC) teams (n=33), hospital laboratory staff (n=40), and data mangers (n=22) regarding epidemiology, surveillance, case definitions, data management, and laboratory procedures. Hospital surveillance coordinators, composed mostly of nurses, joined the ICU physicians during their clinical rounds to identify patients with suspected signs or symptoms of infections. Nurses and doctors were trained to request additional lab tests/procedures to support patient diagnosis. Data on patients with suspect infections were entered on the PDA, in addition to all lab tests/procedures ordered for the patients. The PDA was programmed to alert the physicians and nurses if the patient had one of the 43 infections. Data entered on the PDA was sent from the hospital to NAMRU-3 on a weekly basis for data cleaning and analysis.
A total of 504 infections for 69042 patient days were reported with an overall rate of 7.3 infections/1000 patient days ranging between 5.4-12 infections /1000 patient days in the different hospitals. Almost 50% of the HAIs were pneumonia (241/504), 20% bloodstream infections, and 15% urinary tract infections. A high proportion of the overall infections were device-associated (64%), where ventilator-associated pneumonia (VAP) constituted 92% of the overall hospital-acquired pneumonia. A total of 544 pathogenic isolates were recovered, where 67% were gram negative, 21% gram positive and 12% fungi. An extremely high AMR pattern was identified in the data as 72% of Klebsiella pneumonia and E.coli were ESBL producers, and 75% of S. aureus were Methicillin resistant (MRSA).
The use of the PDAs assisted in raising awareness of all healthcare providers involved in the surveillance system on HAIs. In addition, it increased knowledge of healthcare providers on diagnosis of HAIs and reflected an improvement in patient management within the hospitals.
We discovered one of the keys to having a successful surveillance system is to involve both the nurses and doctors in collecting data and enrolling patients. IPC nurses felt empowered by the additional knowledge they gained and the added responsibility for the project. The use of the PDAs for data entry was a breakthrough for surveillance teams as they provided decision support tools and facilitated the diagnosis of HAIs. The main challenge we faced was obtaining buy-in from several hospital directors who were worried about the reputation of their hospitals when estimating hospital infection rates. Frequent advocacy meetings were held with hospital directors to raise their awareness on the importance of surveillance programs for improving the quality and safety of healthcare provided. Through continued meetings and education, the hospital directors were more open to having surveillance data collected at their hospitals.