����������[1] Horan TC. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infection. Infection control and

hospital epidemiology: 1992;13:606-608

[2] Gastmeier et al. :Definition nosokomialer Infektionen (CDC-Definitionen), 7. Auflage, Berlin 2011, ISBN 978-3-89606-117-8

[3] Gastmeier et al. : Surveillance postoperativer Wundinfektionen,http://www.nrz-hygiene.de/fileadmin/nrz/module/op/indikator/ProtokollOpKISS_KISS_Stand_21_12_2011_IT.pdf

[4] Gastmeier et al. : Modul OP-KISS, Referenzdaten. Berechnungszeitraum: Januar 2006 bis Dezember 2010;http://www.nrz-hygiene.de/fileadmin/nrz/module/op/200601_201012_OP_reference.pdf

[5] Gastmeier et al. : MRSA-KISS: Surveillance-Protokoll Methicillin-Resistenter Staphylococcus aureus in Krankenhäusern;http://www.nrz-hygiene.de/surveillance/kiss/mrsa-kiss/54491cdb/147/469/

[6] Hompage des NRZ http://www.nrz-hygiene.de/index1.htm

[7] Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 1991;91:152S-157S

[8] Emori TG. National nosocomial infections surveillance system (NNIS) : description of surveillance methods. Am J Infect Control 1991; 19:19-35

[9] Mangram AJ, Horan TC, Pearson ML, Silver LC and Jarvis WR.Guideline for prevention of surgical site infection, 1999. Hospital Infection Control PracticesAdvisory Committee. Infection control and hospital epidemiology: 1999;20:250-278

[10] Heininger A, Niemetz AH, Keim M, Fretschner R, Döring G, Unertl K: Implementation of an interactive computer-assisted infection monitoring program atthe bedside. Infection control and hospital epidemiology: 1999;20: 444-7

MDR offers a rapid alert system to prevent spreadof multi drug resistant organisms.

������ �������� �������������������������������� �������� ������������ ��

������ ������������������������������� ���������������� �������� �

���������� ��� ��� ����������� ��� ��F. G. Linck-Velarde1, H. Mischinger1, G. Bernhardt2, W. Schwab-Ganster3, M. Kucher4, G., Feierl5, A. H. Niemetz6, K. Vander7, A. Bogiatzis7

����������� ������������������������ ������������������������������������� �� ������������!��������"��#����$

1 Universitätsklinikum Graz,Universitätsklinik f.Chirurgie,Klin.Abt.f.Allgemeinchirurgie, Graz, Austria, 2 Landeskrankenhaus Voitsberg,Chirurgische Abteilung, Voitsberg, Austria, 3 KAGes-Services / Medizininformatik u. Prozesse,Steiermärkische Krankenanstaltengesellschaft m.b.H., Graz, Austria, 4 KAGes- Services / Administrative Systeme,SteiermärkischeKrankenanstaltengesellschaft m.b.H., Graz, Austria, 5 Medizinische Universität Graz,Institut für Hygiene, Mikrobiologie u. Umweltmedizin,Labor f. Medizinische Bakteriologie u. Mykologie,Graz, Austria, 6 Niemetz KG, Jennersdorf,Austria, 7 Institut f.Krankenhaushygiene und Mikrobiologie,Steiermärkische Krankenanstaltengesellschaft m.b.H., Graz, Austria

� ��������Continuous surveillance of nosocomial infections in general and of nosocomial wound infections (NWI) in surgery in special, is still underdeveloped in Austria,with varying definitions, methodologies and incomparable results. Furthermore a lack of documentation tools to simplify data collection and evaluation didhamper the prospective and steady surveillance of nosocomial infections. Thus the need to have a simple computerized tool, in order to obtain the necessaryinformation on any developing surgical-site infection or other complications, following surgical treatment, was obvious.

Start-up : 2008 an interdisciplinary workforce (surveillance-intelligence-centre, SIC) consisting of experts from several medical disciplines (surgeons, intensivecare doctors, hospital hygiene personal, epidemiologist, microbiologists), IT- and database specialists, statistician and a consultant for IT-based nosocomialinfection control was formed to develop and implement the present NISS modules, NISS-OP (surgical NWI), NISS-ITS (NI in ICU) and NISS-MDR (multi drugresistant pathogens, integrated in all modules). Tasks of the SIC-Team are analyses of data and proof of validity, frequent reporting of data and benchmarkingresults, provide help and support for documenting units, warrant absolute anonymisation of data, communication with reference centres, training courses,development of new modules and lots more.

����������� �� �� ��

Developing tools : Data entry was programmed in ABAP ®. NISS documents (NISS-ITS, NISS-OP) were developed with standard tools of i.s.h.med ® fordeveloping medical documentation. Data are stored in ORACLE® Database 11g release 2.

Parameterization : All parameters as described by NRZ protocols[ 2 - 6] were included and additionally others as used by [10] and some, we found necessary,as antibiotic treatment and a registry of other complications following surgery, were added.

Risk adjustment of surgical procedures : For all key-operations, so called indicator-operations, risk adjustment was set-up according to NRZ protocols [3].

Classification of infections : To obtain standardised diagnoses, NWI were strictly diagnosed and classified by applying CDC-criteria of surgical-site infections[1]. Hence classes A1, A2, A3 were differentiated according to NRZ protocols [3], while no surgical procedures, which could show infections of classes A4, A5,were included.

NISS-Training : Educational courses for participating surgeons were held at each surgical unit. Individual sessions at the documentation site were offered todocumenting surgeons or responsible medical doctors at the surgical wards. A surveillance manual, step-by-step documentation guide and the CDC-criteriawere handed out. A help hot-line was established.

Collection of Surveillance Data : Is done electronically, within openMedocs®, using integrated parameter driven NISS – documents (e.g. NISS-OP [fig.1 - 4]).

Microbiology : data exchange between openMedocs ® and corresponding microbiological laboratories, is fully automated across a platform, that unifiesmicrobiological terms. All three major microbiological laboratories of Styria, which handle KAGes specimen, and NISS are using the same taxonomic names ofpathogens, mainly based on NCBI (National Center for Biotechnology Information, Bethesda, USA) database and the same generic names of antibiotics andantifungal agents. Bacterial names are updated as soon as a change is known. Microbiological data are transferred to NISS several times a day.

Data Evaluation : Data are analysed following NRZ protocols and references [3-5]. Data can be retrieved from the database with SAP business warehouse ®

using a host of queries. Routine reports are generated with SAP business warehouse ®. The resulting tables are exported into MS-EXCEL ® spread sheets forfurther calculations and reporting. A summary report is annual or biannual provided to all participating units, to be used in internal quality management.

��!���

System and Functionality- Complete monitoring of Nosocomial Wound Infections (NWI)

Possibility to record all necessary surveillance parameters:at the operation theatreduring the follow up at the bed-side and out-patients wards

- Setting up an alert system for MDR pathogensRecording of any occurring or known MDR pathogen

- Recording Clostridium difficile isolates and infections- Input of antibiotic prophylaxis and treatment

to optimize antibiotic regiments and habits- Setting up a registry for

“other complications after surgical intervention”Implantations and associated complications

- Standardized Tools and regulations for diagnosis, documentation and evaluation ([1],[2 - 6])

- Fully computer-assisted from Data Input up to reporting of results- Simple, effective and quick to handle- Integration within the existing SAP®-IT Environment and Documentation

System (openMEDOCS®)- Easy implementation into any hospital environment using SAP and

openMEDOCS®

Results and Evaluation- Summarized views on relevant microbiological results at hands- Pre-warning of known occurring multi drug resistant (MDR) organisms- Proof of the chosen antibiotic therapy against found antibiotic

susceptibility patterns- Calculation of risk-adjusted and procedure-specific

stratified infection rates- Export function of results into spreadsheets (e.g. MS-EXCEL®)- Data are securely anonymized- Ready for in-house quality management- Direct Use for international benchmarking

NISS – OP-view: MIBI tab

Fully automated compilation of microbiological isolates and corresponding antibiotic susceptibility data, diagnosed in three out of four microbiologicallaboratories, handling all microbiological specimen in Styria (see Figure 5). Comparison of antibiograms to spot changes under antibiotic therapy, or identicalorganisms isolated from different materials and collection sites (see Figure 6).

������� �All requirements were fulfilled and the desired goals achieved.A computer based surveillance system of nosocomial infections, allowingstandardized data input and data evaluation, will now be rolled-out.

Based on already established surveillance systems KISS and webKess[3,6], National Nosocomial Infections Surveillance (NNIS) system [7 - 9]and previous work on setting up surveillance systems [10], NISS-modules were adapted and extended.

NISS-OP pilot was first rolled out to two surgical units, one general publichospital and one university clinic, in 2010.

NISS-OP enables online documentation and follow up of surveillancedata from surgical interventions, antibiotic treatment, surgical-siteinfections and causing pathogens, occurring and known multi drugresistant (MDR) bacteria, Clostridium difficile carriers and infections aswell as other complications following surgical interventions.

From 2010 until 2012 all surgical treatments were monitored. Since thendata on about 3800 surgical procedures have been collected.

NISS – OP-documentation :

Enables patient based online documentation of surgical interventions,occurring surgical–site infections, causing agents, MDR-pathogens,applied antibiotic therapy and other not infection based complicationsfollowing surgery.

In Figure 1 the input of operation related parameters is shown. NISS-OPconsists of three tabs:

- OP: operation parameters input (operation theatre), antibiotictreatment (operation theatre and surgical ward), documentation ofsurgical-site infections and other complications (surgical ward)

- MIBI: microbiological results (isolates and susceptibility data)

- MDR: multi drug resistant pathogens; documentation and viewFigure 1: Input of operation parameters and antibiotic treatment

"#�$"

Figure 3: Selection of infection causing isolateFigure 2: Input of surgical-site infection NWI Data

Documentation of surgical-site infections is carried out in the OPtab at the surgical wards and in the outpatient department asshown in Figure 2. The input possibility of other complicationsfollowing surgery is located underneath this section but not shownin this figure.

The pathogen responsible for the NWI is selected from the micro-biological data shown in the MIBI tab (see Figure 3). The buttonwith an exclamation mark on yellow background in the MIBI tabheader signals the presence of a multidrug resistant organism.

Figure 4 depicts the documentationsectionof other surgical relatedcomplications. Data are retrieved from DIACOS®System.

Figure 4: Selection and Input of other post-surgical complications

������� ��

Figure 5: Isolates and susceptibility dataFigure 6: Comparison of antibiograms

NISS – OP-view: MDR tab

All known and recorded multi-drug-resistant pathogens are included in theMDR section (see Figure 7, example from NISS ITS, MDR tab is identical toNISS OP). Technically also Clostridium difficile isolates are recorded in thismodule. Pathogens are taken from MIBI tab automatically and can be alsoentered manually.

Figure 7: MDR view and input

Data evaluation I – standard reports:

Figures 8 and 9 show examples of routine reports as generated by queries set up in SAP business warehouse®.

Figure 8: Stratified infection rates according to risk categories Figure 9: Wound infection rates and infection type (detailed view)

Data evaluation II – extended data evaluation and re porting:

Data are exported to MS-EXCEL® spreadsheets for further calculationsand reporting.

In Figure 10 an example of stratified wound infection rates forconventional cholecystectomies (CHOL) is shown. All data stem from oneoperation unit during 2011. There are three main categories:

- risk class stratified wound infection rates

- wound infection rates according to type of infection

- standardized key figure of wound infections (SKI); any value lower orequal than the expected key figure is desirable

The calculation of all these infection rates and key figures enables adirect international benchmarking or can be directly used for in-housequality management purposes.

Risiko Kategorie

N OP / Kategorie

n Wundinfekt.

WI RateWI-Rate

(Referenz)m WI

(erwartet)Mittelwert

25 % Quantil

Median75%

Quantil

0 6 0 %&%% 2,08 0,12 2,08 0 0 2,331 21 0 %&%% 4,13 0,87 4,13 0 3,45 7,14

2,3 5 1 '%&%% 5,61 0,28 5,61 0 3,61 8,82Summe 1,2,3 32 1 (&)( 4,4 1,54 2,63 5,82

SIK erwartet 1,27

CHOL SIK

in House Referenzwerte NRZ-Berlin 2010

Standardisierte Wundinfektionskennzahl (SIK)

0,79

20.03.2012

CHOL

Risiko Kategorie m OP / Kategorie n Wundinfekt. WI Rate Mittelwert 25 % Quantil Median 75% Quantil

0 6 0 %&%% ���� � � ���

1 21 0 %&%% ���� � ��� ���

2,3 5 1 '%&%% �� � ��� �����

Summe 1,2,3 32 1 (&)( ��� ��� �� ���

*��+�,-.�/� ���� *��01�'-.�/� ����

Referenzwerte NRZ-Berlin 2010

stratifizierte Wundinfektionsrate

Cholezystektomie (offen chirurgisch)

��� ��0�*��01�,-.�/� ���� '-.�/� �����0�*��01� ��� �

WI Art m IOP n Wundinfekt. WI Rate Mittelwert 25 % Quantil Median 75% Quantil

A1 1 (&)( 3,7 0 2,35 4,88A2 0 %&%% 1,11 0 0,31 1,99A3 0 %&%% 0,62 0 0 1,08

Summe 32 1 (&)(

*��+�,-.�/� ����

Wundinfektionsraten nach Art der Infektion Referenzwerte NRZ-Berlin 2010

��� ��0�*��01�,-.�/� ���� '-.�/� �����0�*��01� ��� � *��01�'-.�/� ����

Figure 10: Example of wound infection rates in the exporteddata sheet for results out of NISS-OP

Implementation of the NISS-OP

- Roll-Out of NISS-OP to some 80 surgical units of public and university hospitals in Styria within KAGes (as shown below) should bestarted by 2012 and finalized 2013

A standardised documentation system for the surveillance of nosocomial infections in surgical units has been developed. Hence NISS provides participatingunits with a strategic tool to continuously improve safety and quality of surgical treatment.NISS-OP allows completely computerized monitoring of nosocomial wound infections. An alert system for MDR pathogens, recording of Clostridium difficileisolates and infections, the documentation of antibiotic prophylaxis and treatment, their out-come and undesirable side effects, as well as the possibility to setup any kind of operation or infection related registries (application of new surgical material like meshes, joints, suture or operation techniques or complicationsrelated to surgery, antibiotic regiment) are just part of its multiple features.NISS-OP is fully integrated within the hospital information system and able to link different worlds of data. Hence providing surgical entities not only with a toolto benchmark their efforts on an international level and enhance in-house quality management, but also yielding a complete multi-centric record of a patientsmicrobiological isolates and their corresponding susceptibility, at one glimpse.Data – input und evaluation are standardized following approved methods for diagnosis and documentation, still it is quick, effective and easy to handle.It fulfils all governmental demands, while still keeping data completely anonymized. NISS-OP ensures complete data recording, targets at improving antibiotictreatment. Helps to fight and avoid life threatening nosocomial infections, and improves safety for patients and medical staff.

Helpful necessities : Mutual interest of the hospital management to avoid nosocomial infections. On a governmental level the awareness of the dangerousthreat of nosocomial infections and their impact on treatment costs for public health services. A legal framework regulating the surveillance of nosocomialinfections. A dedicated nosocomial infection control group to stem the staggering task of protecting patients and medical staff by reducing nosocomialinfections, and improving infection control surveillance.

Starting January 2012 NISS-OP will be rolled out to 78 surgical units more in Styria.

$����������

Contact:

Dr. Federico Guillermo Linck-VelardeUniversitätsklinik für ChirurgieAuenbruggerplatz 29A-8036 Graz

Tel.: +43/316/385/81209 e-mail: guillermo.linck@meduni-graz.at

���������� ��� ������������������ ���� ������������� �

���������

���������������� ����������

���������� ��� ��� ����������� ��� ��B. F. Höfler1, B. Höfler2, F. G. Linck-Velarde2, A. H. Niemetz3, A. Bogiatzis4, H. Metzler1, H. Mischinger2

Dr. Barbara Höfler Univ. Klinik für Anästhesiologie und Intensivmedizin/LKH-Graz

1 Universitätsklinikum Graz, Universitätsklinik für Anästhesiologie und Intensivmedizin, Graz, Austria, 2 Universitätsklinikum Graz, Universitätsklinik für Chirurgie, Klin. Abt. für Allgemeinchirurgie, Graz, Austria, 3 Niemetz KG, Jennersdorf, Austria, 4 Institut für Krankenhaushygiene und Mikrobiologie, Steiermärkische Krankenanstaltengesellschaft m.b.H., Graz, Austria

���������

Health care-associated infections from invasive medical devices in Intensive Care Units (ICU’s) are a major threat to patient recovery. In 2008 an interdisciplinary workforce (surveillance-intelligence-centre, SIC) was formed to develop and implement the NISS Intensive CareModule (NISS-ITS) for continuous surveillance of nosocomialinfections in Intensive Care Units.In 2010 NISS-ITS Nosocomial Infection Surveillance System (NISS) was introduced in selected ICU’s in the province of Styria to assess the incidence rates of nosocomial infections.

�� ���

NISS-ITS was introduced to two surgical and one general ICU in 2010. From 1st of January to 31st of December 2010 a total of 2064 patients were admitted to these ICU’s equal to 9600 patient days.Respiratory tract infections (RTI’s) in patients with non invasive ventilation were most frequent (32% of all infections), followed by RTI’s in patients with invasive ventilation (27%), urinary tract infections (UTI’s) (27%), and central line infections causing sepsis (14%). 100% of urinary tract infections were associated with urinary catheters. In a comparative analysis infection rates were shown to be within international ranges whereas device days appear to be slightly higher in our institution. NISS-ITS was demonstrated to be a powerful tool to increase patient safety, provides highly relevant data and fulfills all legal requirements.It was shown to be ready for roll out to all other Intensive Care Units within the KAGes.

!���� �

NISS Intensive Care Module has made for a better appreciation of the associated risks of medical devices in Intensive Care Units and has allowed comparative evaluation and benchmarking of infection rates. Data entry was proven to be intuitive, effective and quick.

���������

Urinary tract infection, assoc. with urinary catheterRespiratory tract infection,

non invasive ventilation

Respiratory tract infection, assoc. with invasive ventilation

Sepsis,Central venous line

���"��� ��� #�������� �������� ���$

A documentation system was developed allowing continuous computer assisted documentation, processing and interpretation of surveillance data. Integration within the existing SAP®-IT Environment and Documentation System (openMEDOCS®) and automatic retrieval of information from other NISS modules (NISS-Multi Drug Resistance and NISS Microbiology) were prerequisites to enhance acceptance among users. In a pilot phase NISS-ITS was introduced to three Styrian ICU’s. Data entry strictly followed international guidelines for the classification of nosocomial infections. Nosocomial infections were analysed by infection site, pathogen distribution and resistance pattern within a one year period.Features were then compared with data from the European Reference Center in Berlin (NRZ).

���������� ��� ��� �

������%� ��&'('

BH1

Folie 1

BH1 Barbara Höfler; 17.04.2012

���������� ��� ������������������ ���� ����� ���������

��������

���������������� ����������

���������� ��� ��� ����������� ��� ��B. Höfler1, B. F. Höfler2, F. G. Linck-Velarde1, A. H. Niemetz3, A. Bogiatzis4, H. Metzler2, H. Mischinger1

Dr. Bernd Höfler (bernd.hoefler@klinikumgraz.at) Abteilung für Allgemeinchirurgie, Univ. Klinik für Chirurgie/LKH-Graz

1 Universitätsklinikum Graz, Universitätsklinik für Chirurgie, Klinische Abteilung für Allgemeinchirurgie, Graz, Austria, 2 Universitätsklinikum Graz, Universitätsklinik für Anästhesiologie und Intensivmedizin, Graz, Austria, 3 Niemetz KG, Jennersdorf, Austria, 4 Institut für Krankenhaushygiene und Mikrobiologie, Steiermärkische Krankenanstaltengesellschaft m.b.H., Graz, Austria

���������

Surgical Site Infections (SSI) are a substantial risk for the patient, are associated with considerable morbidity, extended hospital stay and result in a considerable financial burden to healthcare providers. A modular Nosocomial Infection Surveillance System (NISS) was introduced in 2010 in selected Styrian hospitals in order to collect relevant data on the occurrence of hospital-acquired infections and to allow corrective measures.NISS-OP is one of four NISS modules and focuses on Surgical Site Infections.

�� ���

In a pilot project NISS Operation Module (NISS-OP) was introduced to the General Surgical Department of the Medical University Graz in July 2010. Within a one-year period specifications of 540 operations were collected. Primary data entry required 10 mouse clicks on the screen equal to 20 seconds per patient because most of the information was automatically retrieved from Hospital software (MEDOCS). Therefore acceptance among surgeons was high. Comparative evaluation showed that risk class stratified wound infection rates and standardized key figure of wound infections (SIK) were within the normal range in most indicator operations. However, wound infection rates following appendectomy were above the expected key figure.NISS-OP was well accepted, it provides valuable information for quality management purposes and improves patient safety. The calculation of infection rates and key figures for the first time enabled a direct international benchmarking. It fulfills all legal requirements and was shown to be ready forimplementation in all surgical departments within the KAGes.

!���� �

NISS has made for a better appreciation of the associated risks and allows for comparative evaluation of infection rates. A guided rollout in other surgical departments will follow in due course. Data entry was proven to be intuitive, effective and quick.

"��������

A documentation system was developed allowing continuous computer assisted documentation, processing and interpretation of surveillance data. Integration within the existing SAP®-IT Environment and Documentation System (openMEDOCS®) and automatic retrieval of information from other NISS modules (NISS-Multi Drug Resistance and NISS Microbiology) were prerequisites to enhance acceptance among users. Educational courses for participating surgeons were held at eachsurgical unit. Individual sessions at the documentation site were offered to documenting surgeons or responsible medical doctors at the surgical wards. A step-by-step documentation guide and a surveillance manual were handed out. SSI were strictly diagnosed and classified applying criteria of the Center for Disease Control and Prevention (CDC), Atlanta, USA. Infection classes A1, A2, and A3 were differentiated and infection rates were then compared with data from the European Reference Center in Berlin (NRZ). Surgical Site Infections were analysed by infection site, pathogen distribution and resistance pattern within a one year period.

Risiko Kategorie

N OP / Kategorie

n Wundinfekt.

WI RateWI-Rate

(Referenz)m WI

(erwartet)Mittelwert

25 % Quantil

Median75%

Quantil

0 6 0 #$## 2,08 0,12 2,08 0 0 2,331 21 0 #$## 4,13 0,87 4,13 0 3,45 7,14

2,3 5 1 %#$## 5,61 0,28 5,61 0 3,61 8,82Summe 1,2,3 32 1 &$'& 4,4 1,54 2,63 5,82

SIK erwartet 1,27

CHOL SIK

in House Referenzwerte NRZ-Berlin 2010

Standardisierte Wundinfektionskennzahl (SIK)

0,79

20.03.2012

CHOL

Risiko Kategorie m OP / Kategorie n Wundinfekt. WI Rate Mittelwert 25 % Quantil Median 75% Quantil

0 6 0 #$## ���� � � ���

1 21 0 #$## ���� � ��� ���

2,3 5 1 %#$## �� � ��� �����

Summe 1,2,3 32 1 &$'& ��� ��� �� ���

(�)�*+,�-�� �� (�./�%+,�-�� ��

Referenzwerte NRZ-Berlin 2010

stratifizierte Wundinfektionsrate

Cholezystektomie (offen chirurgisch)

������.�(�./�*+,�-�� �� %+,�-�� ���.�(�./������

WI Art m IOP n Wundinfekt. WI Rate Mittelwert 25 % Quantil Median 75% Quantil

A1 1 &$'& 3,7 0 2,35 4,88A2 0 #$## 1,11 0 0,31 1,99A3 0 #$## 0,62 0 0 1,08

Summe 32 1 &$'&

(�)�*+,�-�� ��

Wundinfektionsraten nach Art der Infektion Referenzwerte NRZ-Berlin 2010

������.�(�./�*+,�-�� �� %+,�-�� ���.�(�./������ (�./�%+,�-�� ��

Primarydata entryon thescreen:

Comparative evaluation - open cholecystectomy: