Description of the system

The HAI surveillance network started reporting in May 2017 with 20 sites (66 ICUs) and increased to 39 sites (29 public and 10 private) with 131 surveillance units (ICUs) across 22 of the 36 states and union territories of India as of December 2021. Reporting ICUs included 26/131 (20%) medical, 19/131(19%) neonatal, 16/131 (12%) pediatric medical, 14/131 (11%) surgical, 10/131 (8%) COVID-19 ICUs, and others. At the reporting ICU, the BSI event data flow starts once a patient admitted to one of the surveillance units has a positive blood culture (Fig. 1). This patient’s case details are checked to see if they fit the BSI case definition. If yes, then a case report form (CRF) is generated by the surveillance staff, and it is uploaded into the HAIS web portal by the data entry operator after validation by the site principal investigator (PI). Using the BSI case numbers and the denominator data from the respective sites, facility and network level rates are generated and communicated to all stakeholders. To identify concerning BSI trends and outbreaks, the network database’s early warning signal generates an alert to users automatically when an ICU-specific BSI rate exceeds 20 per 1,000 patient days in that reporting unit/ ICU.

Fig. 1

Data flow in HAI Network’s Bloodstream Infection Surveillance (BSI), India, 2022

The network received funding support from the US CDC under a cooperative agreement between 2017–2022 technically coordinated by ICMR. The CDC funding was provided to AIIMS, and AIIMS distributed the funds to the funded sites to hire surveillance staff depending on the units under surveillance. Sites that are not funded by the AIIMS-CDC projects and are part of the surveillance network as voluntary participants receive technical support and reporting platform access. They use internal funds to hire surveillance staff or use existing staff for surveillance activities. Material resources for data collection and any additional human resources required for surveillance expansion are financed through the site’s internal budget.

Evaluation of the system: Quantitative results

At the network level, we reviewed 21 site visit reports, 14 quarterly reports, data reported to the network database from 1st May 2017 to 31st December 2021, and 284 CRF. Ten hospitals agreed to participate in our evaluation. At the reporting level, surveys were distributed to 20 surveillance staff (two from each of the 10 sites), 20 DEOs (two from each of the 10 sites), and 20 physicians (two from each of the 10 sites). Among these, all the surveillance staff, all DEOs and ten physicians responded. Surveillance staff who responded to the surveys included infection control nurses (ICN), laboratory technicians, and research fellows (RF). We visited four (two funded and two non-funded) sites. We reviewed 135 ICU patients clinical case files, 72 positive blood culture reports (reported during the evaluation period) and 26 CRFs (reported during the evaluation period) from six surveillance ICUs in these four sites to evaluate system attributes (Table 3).

Table 3 Evaluation results of HAI Network’s BSI Surveillance system attributes, India, 2022Simplicity

Among the surveyed staff, 83% rated the modified NHSN case definitions as easy to apply and found the online reporting platform user-friendly.

Stability

The network functioned throughout these five years (May 2017 to December 2021) with variable reporting. The number of reporting ICUs dropped from 125/131 (95%) in February 2020 to 84/131 (64%) in April 2020 coinciding with the start of the COVID-19 pandemic. Reporting gradually increased to 100% in March 2021 before decreasing again in April 2021 during the second wave of COVID-19. The reporting increased till August 2021(128/131, 98%) before decreasing again to 63/ 131 (48%) in December 2021 when external funding for this project was interrupted (Fig. 2). Despite reduced project funding, 25% of the hospitals continued to provide data to the system with their own dedicated infection prevention and control (IPC) staff.

Fig. 2

Reporting pattern of HAI Network ICUs reporting BSIs, May 2017 to December 2021

Among the 21 site visit reports reviewed, 76% of sites reported that surveillance staff had access to all positive cultures (cultures taken from other body sites). All sites which reported challenges in surveillance staff accessing all positive culture reports were public hospitals. These hospitals used manual registers for recording and reporting laboratory results and did not have a Laboratory Information System (LIS) or Hospital Management Information System (HMIS).

Representativeness

Among the 135 ICU patient case files reviewed, blood culture was collected within 24 h in 27/61 (44%) febrile episodes identified in these patient files. Two of these hospitals cultured blood based on patient symptoms (with 44% of patients being cultured within 24 h of a febrile episode in both hospitals), and the other two hospitals cultured patients twice a week irrespective of patient symptoms (26% and 62% of patients having a febrile episode being cultured in each hospital respectively). Eight physicians reported sending paired blood cultures from each febrile patient, while five physicians reported culturing up to 80% of febrile patients in their ICU.

Data quality

Among the 284 CRFs reviewed, 91% had complete data, and 98% had correctly applied the BSI case definition.

Timeliness

From 2017, the network submitted 13/14 (93%) quarterly HAI surveillance reports to the Ministry of Health and Family Welfare within one month of the reporting quarter. Of the ten ICU physicians surveyed, 60% reported receiving consistent monthly feedback on BSI rates from their ICUs.

Sensitivity

Among 72 positive blood cultures reports reviewed, 26 positive blood cultures and their corresponding patient case files met the BSI case definition criteria and all 26 were correctly reported as BSIs by the sites to the network database. The 14 quarterly reports reported on pooled network trends mapped for each quarter. The system generated 684 ICU-specific BSI rate alerts from May 2017 to December 2021.

Positive Predictive Value

All 26 CRFs reported from site-level surveillance staff to the network database during site visits met the BSI case definition, with a positive predictive value (PPV) of 100%.

Usefulness

Using data from this network, 12 of the 39 (31%) participating sites had implemented targeted IPC measures to reduce their BSI rates. Three major healthcare-associated BSI outbreaks, including an outbreak caused by Burkholderia cepacia, were detected and controlled [14]. Among surveyed physicians, 70% stated that surveillance data feedback positively impacted care in the ICU by improving documentation and increasing adherence to recommended central-line practices.

Evaluation of the system: Qualitative results

At the network level, we conducted three interviews (the program coordinator, one statistician, and one research fellow of the HAI surveillance program) and one FGD (with three technical advisers from the US CDC). At the site level, we conducted ten interviews (one per site, with one to two staff participating in each). The interviewees included six microbiologists, four ICNs, six RFs, and two DEOs. The qualitative analysis from the interviews yielded ten themes related to implementing the surveillance (Tables 4 and 5).

Table 4 Summary of Themes from Qualitative Analysis, BSI Surveillance Evaluation, India, 2022Table 5 Themes, codes and representative quotes obtained from interviews, HAI Network’s BSI Surveillance evaluation, India, 2022

Mixed-methods integration: We consolidated the quantitative attributes, their indicators, and the qualitative themes under best practices, challenges, and opportunities (Table 6). Best practices encompassed developing case definitions suitable for the available resources in a diverse health system, establishing network-based surveillance, and IPC training of surveillance staff. Challenges identified included limited human resources, lack of digitalization, variable blood culturing practices, inconsistent information sharing, funding, and the COVID-19 pandemic. Opportunities highlighted the awareness and acceptance of BSI surveillance among participating sites.

Table 6 Integration of qualitative themes and quantitative indicators, HAI Network’s BSI surveillance evaluation, India, 2022

In all domains, the evidence from surveys, interviews, and document reviews aligned with each other except in blood culturing practices. While the surveyed physicians reported culturing 80% of febrile patients, document reviews indicated a figure of 44%.