Hospital Healthcare Europe
In the past few years, the dramatically escalating number of MRSA cases as well as other dangerous infections has led to increasing calls for the return of the “matron” and far higher standards of hygiene in hospitals. However, the statistics regarding nosocomial infections continue to shock. In the extended European Union, there are approximately three million nosocomial infections and 50,000 attributable deaths per year.
Infections acquired in intensive care units (ICUs) increase patients’ morbidity, length of stay and costs of hospitalisation. To help combat this – or at least lay the groundwork for a possible improvement in these worrying statistics – in 1994, the regional and national public health institutes in charge of the coordination of hospital-acquired infection (HAI) surveillance set up the collaborative network HELICS (Hospitals in Europe Link for Infection Control through Surveillance).
The European-funded programme’s main objective is to create a Europe-wide database, intended for the comparative analysis of the rates of HAIs in all the countries of the EU. According to those running the HELICS project, nosocomial infections in particular present different and specific challenges compared with the surveillance of other infections because their clinical, microbiological, epidemiological and even physiopathological features are heterogeneous.
The project consists of an ICU physician and an epidemiologist from the surveillance network or public health institute together with members of the European Society of Intensive Care Medicine who monitor patients as they enter and leave the intensive care wards. The protocols of each country were analysed to assess the feasibility of a retrospective comparison of the indicators between national and regional networks. A questionnaire was also distributed among the members of the working group, to manage the necessary consensus required to establish a new standardised protocol.
As part of the HELICS project, national and regional networks for the surveillance of HAIs in ICUs now exist in six EU Member States: Belgium, Germany, Portugal, Spain, the Netherlands and France.
After numerous roundtable discussions it was decided that the surveillance of bacteriemiae and pneumoniae would become a priority, followed by the surveillance of urinary tract infections and catheter colonisations.
Lyon University’s Ian Russell, who has previously worked for the health service in Scotland, is now assisting in the validation of the vast amounts of data that stream back to his office. While Lyon University may be heading up the project, the statistical analysis of the data is undertaken by specialist epidemiologists in Brussels.
“We are trying to set standards in Europe, and we have two protocols which define the way we do surveillance. It is largely on a voluntary basis that countries have started to implement these kinds of protocols in their hospitals,” said Russell.
He added: “It’s a really effective way for practitioners in Europe to get some comparison with other European countries. Reoccurring instances of infections and information about certain risk factors, for example.” The HELICS database goes back to 2000, with retrospective data collection covering the 2000–2003 period followed by contemporaneous data from 2004 onwards.
There is a large variety of data items to be collected. As well as the examples mentioned above, hospital staff also collect data pertaining to the patients’ age, gender, date of admission, wound contamination class (whether it is clean or not) and duration of stay. Additionally, factors such as the ASA severity score, whether the patient has an infection, and if so the date of it, what it was and a hospital code are also being collected. All patients are monitored, whether they have become infected or not. All of these datasets are then collected at a national level, with hospital codes being used so that the hospitals can remain anonymous.
The information is collected annually, and then a yearly report is put together, with the latest report due out later this year.
“One of the difficulties is that it is a really long-term activity,” explained Russell. “Even though we’ve agreed this common protocol, we can’t say with certainty that the protocol is being applied in the same way in different countries.”
Variations in protocol
There are numerous differences in the surveillance protocols, particularly concerning the type of infection documented, the case definitions used (particularly for pneumonia), the population studied (for example, all patients or only those who have spent more than 48 hours in an ICU) or the definition of “one-day use” of a device (for example, inclusion or not of noninvasive, mechanically assisted ventilation). It is possible that even the risk factors collected for each patient could vary.
“Surgeons in different countries might have different ways of evaluating patients. There is no way of knowing if this is true – and we are not assuming it is – but we need some longer-term validation,” said Russell.
In the short term, one of the main benefits of the HELICS project is that it helps countries to set up their surveillance systems and monitor their patients in a more effective manner. These short-term benefits have proved particularly useful for those countries in the EU which are slightly less advanced, as it then lets them learn and benefit from some of the other, more experienced, countries. “The aim is to help us work towards a common European approach,” stressed Russell.
Certainly the signs look encouraging. Complementary studies running alongside HELICS have already managed to link nosocomial infection rates to patient care quality parameters.
HELICS is funded by the Directorate General of Health and Consumer Protection and is now part of improving patient safety in Europe as part of a wider project. HELICS also fits into a growing trend in Europe for all of its research and surveillance of infections to be pooled together. “The work that we do is a concern of the new European Centre for Communicable Diseases, which is being set up in Stockholm, and we will be evaluated this year to see if they want to continue the HELICS project. If they are interested then there are a number of possibilities for the future – we’ll just have to wait and see.”