Protection of patients and health workers from infections during health care delivery has been a high priority for the German government since many years. This is demonstrated by their very advanced national infection prevention and control (IPC) programme, reinforced by the German federal law – an excellent example of implementing the WHO-recommended core components for IPC.
A unique strength of this programme is an efficient system for the surveillance of infections acquired during health care (health care-associated infections [HAIs]). After introducing this innovative system in 1997, Germany has seen significant reductions in infection rates.
How and where did they start?
A voluntary and confidential national system for HAI surveillance – the Krankenhaus-Infektions-Surveillance-System (KISS) – started in 1997, with a small number of participating hospitals. KISS then grew from year to year and now consists
of several HAI surveillance components spanning a range of patient populations and areas: intensive care units (ICUs), neonatology, intensive care patients with very low birth weight, hematology-oncology patients, surgical patients, non-ICU patients with vascular or urinary
catheters and outpatients with ambulatory operations. Finally, components for hospital-based surveillance of multidrug-resistant organisms and for alcohol-based hand rub consumption have been introduced.
Most German hospitals participate in at least one surveillance component and, since 2001, all hospitals perform surveillance for certain infection types which are relevant for their patients, according to the German infection protection act. The data must be analysed and reported to staff, appropriate action taken and IPC measures implemented at the point of care based on the results. Compliance with these requirements are assessed by the local health authorities regularly.
KISS demonstrated the tremendous benefits of ongoing surveillance activities and feedback to hospitals in combination with reference data, achieving significant reductions in infection rates, more specifically, a marked reduction between 20–30% of infections in various surveillance periods in the components for ICUs, operative departments and neonatal ICUs.
Figure 1: Temporal development of incidence densities of nosocomial infection in very low birth weight infants on
neonatological departments (NEO-KISS 2008–2021, unpublished data from 250 neonatal departments at Charité hospital)
IDPNEU: incidence density pneumonia; IDNEC: incidence density NEC; IDSEP: incidence density primary bloodstream infections
One of the biggest benefits of the national surveillance system has been the ability to use data for improvement and as a measure of quality performance for staff and institutions. Surveillance is a primary driver for reducing HAIs also due to the implementation of evidence-based practices and appropriate tailoring of interventions in addition to feedback on the infection rates in comparison with reference data.
Success factors
The German experience has identified a set of attributes in building a successful surveillance system: simplicity, flexibility, acceptability, representativeness, timeliness, stability and the provision of high-quality data.
KISS works like a network, and the participants learn from each other by demonstrating their individual success stories in decreasing infection rates but also sharing their experiences when efforts were unsuccessful. Annual meetings are organized to present the latest data, discuss challenges and determine relevant actions based on new developments in the field.
The quality of data feedback is fundamental in translating surveillance results into action, so data presentation and visualisation in tables and figures are continuously assessed and improved. Timely dissemination of the data to those who will use them to prevent and control infections is also key.
Training is important to ensure that HAI case definition criteria and protocols are accurately and consistently applied. KISS has conducted training on HAI diagnosis according to pre-set definitions by case studies, and tools for periodically testing data accuracy are made available.
Having an online data management system has been fundamental to handling the increasing number of participating hospitals and provide technical management and support and timely, regular data feedback.
The fact that IPC is reinforced by legislation within the German federal law makes an essential contribution to achieving consistent implementation of legal targets by enforcement agencies and by the responsible players in medical institutions.