design. This panel consisted of 12 experts that were either National Focal Points for HAI, infection prevention and control doctors, intensive care physicians, surgeons or epidemiologists, known for their clinical and research experience in HAI. The study group, including both project group and expert panel, met to discuss the three‐category mortality review measure (3CAT) developed by Kaoutar et al (10) and evaluated in 16 French hospitals. We added two alternative measures: one based on the World Health Organization (WHO) death certification methodology that is widely applied by clinicians (11) (WHOCAT) and a quantitative Likert scale from 0 to 10 (QUANT), to enable a more visual assessment (12) (Box). Pneumonia, bloodstream infection (BSI) and Clostridioides difficile infection were selected for evaluation as these HAI are recorded within two HAI‐Net modules (European surveillance of healthcare‐associated infections in intensive care units (pneumonia and BSI)(13) and European surveillance of C. difficile infections(14)) and are both frequent and associated with increased mortality(2). During the expert meeting, the panel evaluated the feasibility and validity of the three outcome measures with a number of case vignettes. Hospital recruitment The ECDC national focal points for HAI of all countries contributing to HAI‐Net were invited by email to recruit hospitals in their country, preferably those performing HAI surveillance for ICU‐acquired HAI, and/or CDI, applying the ECDC surveillance protocols (13‐15). Review procedure On‐site investigators attended the kick‐off meeting, where the review procedure and the data to be collected were explained and discussed. Adult patients aged 16 years and older were included if they had BSI or pneumonia (most often, but not exclusively, ICU‐acquired, defined as occurring after more than 48 hours in ICU) or CDI, and subsequently died during the same hospital/ICU stay. Cases with SSI could be included but were not the focus of the study. A local team consisting of an on‐ site investigator (OSI; usually an infection prevention and control doctor or ICU physician) and a treating physician (TP) evaluated the patient records. The reviews were performed within ca 1 month of the death, to enable recollection of relevant details. For each deceased patient with an HAI, the OSI and TP independently assessed the contribution of the HAI to the patient’s death, using the three outcome measures (Box). They subsequently discussed the case aiming to reach a consensus. Agreement or disagreement was recorded both before and after the discussion. 108 Chapter 6
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