NSIH - Quality indicators for hospital hygiene in acute care hospitals (NSIH_QI)
- from 01/01/2024 - 31/12/2024
- Status: active
- Unique ID: reference year
- How to create a CSV file for this data collection?
- Start date: 31/12/2024
Reference year
Not to be included in the CSV.
Technical specs
CSV column name:
NR_YR_REF
Default value:
2024
Required:
true
Read only
1 Organisation
There is a general long-term strategic plan (3-5 years) for healthcare-associated infection prevention and control, developed by the infection control team and approved by the infection control committee.
Technical specs
CSV column name:
CD_STRAT_PLAN
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
This strategic plan is integrated into the hospital's strategic plan.
Technical specs
CSV column name:
CD_STRAT_PLAN_HOSP
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Number of meetings of the infection control committee.
Technical specs
CSV column name:
MS_MEET_HHC
Required:
true
A detailed action plan for healthcare-associated infection prevention and control was developed by the infection control team and approved by the infection control committee.
Technical specs
CSV column name:
CD_HCIPC_APPROVED
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An annual report on healthcare-associated infection prevention and control activities was developed by the infection control team and approved by the infection control committee in the previous year.
Technical specs
CSV column name:
CD_HCIPC_REPORT_APPROVED
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The infection control nurse(s) who is/are part of the legally determined minimum required number of staff, is/are part of the nursing middle management.
Help
See B4 of the financial resources budget
Technical specs
CSV column name:
CD_NURSE_MGM
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Responsible infection control physician
Help
This is a purely operational question, which is not scientifically required.
Technical specs
CSV column name:
CD_RIZIV_INFCT_CTRL_PHYS
Length:
11
Reference list:
PHYSICIAN
Required:
true
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.HealthProfessional
Data element:
HealthProfessionalIdentificationNumber
2 Means
The EFFECTIVE number of infection control physicians in the hospital this year.
Help
Expressed in number of FTE
Technical specs
CSV column name:
MS_INFCT_CTRL_PHYS
Required:
true
Validation
- This number seems high. Please check again. (warning)
The EFFECTIVE number of infection control nurses in the hospital this year.
Help
Expressed in number of FTE
Technical specs
CSV column name:
MS_INFCT_CTRL_NURSE
Required:
true
Validation
- This number seems high. Please check again. (warning)
Number of intensive care units (ICUs) in the hospital.
Help
If the hospital does not have an intensive care unit, fill in 0.
Technical specs
CSV column name:
MS_ICU
Required:
true
Total number of units under the supervision of a head nurse in the hospital.
Help
Including ICUs
Technical specs
CSV column name:
MS_UNITS_NURSE
Required:
true
The hospital has established referents for infection control.
Technical specs
CSV column name:
CD_HYG_REF
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Number of referents in ICUs.
Technical specs
CSV column name:
MS_ICU_REF
Only when:
, ,
Required:
true
Total number of referents in infection control in units under the supervision of a head nurse.
Help
Including ICUs
Technical specs
CSV column name:
MS_REF_NURSE
Only when:
Required:
true
Total number of hours for internal training on infection control provided by the infection control team to the hospital staff.
Help
For new staff, nursing staff, medical staff ...
Technical specs
CSV column name:
MS_HYG_TRAIN_H
Required:
true
Total number of participants in these trainings on infection control in the year.
Technical specs
CSV column name:
MS_HYG_TRAIN_PTCP
Required:
true
Total number of hours of e-learning training on infection prevention followed by the hospital staff.
Technical specs
CSV column name:
MS_HCIPC_ELEARN_H
Required:
true
3 Activities
3.1 Meetings
The management attends the meetings of the infection control committee.
Technical specs
CSV column name:
CD_MGM_MEET
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The infection control team attends the meetings of the regional platform for infection control.
Technical specs
CSV column name:
CD_HOSP_HYG_TEAM_MEET
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
3.2 Surveillances
A local surveillance of Methicillin-resistant S. aureus (MRSA) exists.
Technical specs
CSV column name:
CD_LOCL_SURV_MRSA
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The hospital participated in the national surveillance of MRSA by providing the required aggregated data.
Technical specs
CSV column name:
CD_NATIO_SURV_MRSA
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
A local surveillance of hospital-associated bloodstream infections exists.
Technical specs
CSV column name:
CD_LOCL_SURV_BSI
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The hospital participated in the national surveillance of bloodstream infections by providing the required data.
Technical specs
CSV column name:
CD_NATIO_SURV_BSI
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
A local surveillance of multi-resistant Gram-negative bacteria exists.
Technical specs
CSV column name:
CD_LOCL_SURV_MRGNB
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The hospital participated in the national surveillance of multi-resistant Gram-negative bacteria by providing the required aggregated data.
Technical specs
CSV column name:
CD_NATIO_SURV_MRGNB
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
A local surveillance of toxigenic C. difficile-infections exists.
Technical specs
CSV column name:
CD_LOCL_SURV_TCDI
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
A local surveillance of infections in Intensive Care Units (ICUs) exists.
Technical specs
CSV column name:
CD_LOCL_SURV_ICUI
Only when:
,
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
A local surveillance of surgical site infections exists.
Technical specs
CSV column name:
CD_LOCL_SURV_SSI
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
| Not applicable | 9 |
Not applicable: motivation.
Help
Motivation for choosing "not applicable" (For example: the hospital has no operating rooms).
Technical specs
CSV column name:
TX_LOCL_SURV_SSI
Only when:
Required:
true
A local surveillance of vancomycin-resistant enterococci exists.
Technical specs
CSV column name:
CD_LOCL_SURV_VRE
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Another local surveillance of healthcare-associated infections/multi-resistant bacteria than those described above exists.
Technical specs
CSV column name:
CD_SURV_OTH
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Which one(s)?
Technical specs
CSV column name:
TX_SURV_OTH
Only when:
Required:
true
A systematic interaction between the laboratory and the infection control team, allowing quick and easy sharing of the list of microorganisms, for which additional precautions are required (warning system) exists.
Technical specs
CSV column name:
CD_INTERACTION
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
3.3 Process audits
An approach for optimizing the choice of venous vascular access depending on the risk of infection exists.
Technical specs
CSV column name:
CD_APPR_VASC
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure for the prevention of central line-associated bloodstream Infections exists.
Technical specs
CSV column name:
CD_UPD_PROC_BSI
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Compliance with this procedure was subject to an audit.
Technical specs
CSV column name:
CD_COMPLIA_AUDIT_BSI
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure for the prevention of catheter-associated urinary tract infections exists.
Technical specs
CSV column name:
CD_UPD_PROC_CAUTI
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Compliance with this procedure was subject to an audit.
Technical specs
CSV column name:
CD_COMPLIA_AUDIT_CAUTI
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure for the prevention of infections related to invasive mechanical ventilation (endotracheal tube) exists for patient on intensive care.
Help
Excluding neonatology
Technical specs
CSV column name:
CD_UPD_PROC_VENTIL
Only when:
,
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Compliance with this procedure was subject to an audit.
Technical specs
CSV column name:
CD_COMPLIA_AUDIT_VENTIL
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure for the prevention of surgical site infection exists.
Technical specs
CSV column name:
CD_UPD_PROC_SSI
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
| Not applicable | 9 |
Not applicable: motivation.
Help
Motivation for choosing "not applicable" (For example: the hospital has no operating rooms).
Technical specs
CSV column name:
TX_UPD_PROC_SSI
Only when:
Required:
true
Compliance with this procedure was subject to an audit.
Technical specs
CSV column name:
CD_COMPLIA_AUDIT_SSI
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The hospital conducts other audits related to infection control than those described above.
Technical specs
CSV column name:
CD_AUDIT_OTH
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Which one(s)?
Technical specs
CSV column name:
TX_AUDIT_OTH
Only when:
Required:
true
3.4 National campaign/prevalence study
The hospital participated in the national champagne ‘You’re in good hands'.
Technical specs
CSV column name:
CD_CAMPGN_YRIGH
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The hospital performs local audits related to hand hygiene compliance, outside the national campaign.
Technical specs
CSV column name:
CD_CAMPGN_OTH
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Total number of observed opportunities.
Help
Outside the national campaign
Technical specs
CSV column name:
MS_CAMPGN_OPPORT
Only when:
Required:
true
The hospital participated in a point prevalence survey related to healthcare-associated infections and antimicrobial use.
Technical specs
CSV column name:
CD_SURV_PNTPREV
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
3.5 Procedures
Information for the patient
Fields
Information for the patient regarding the risk of infections exists.
Technical specs
CSV column name:
INFO_PAT|CD_INFO_INFCT_RISK
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Accidental blood exposure
Fields
A policy for the prevention of accidental blood exposure exists.
Technical specs
CSV column name:
ABE|CD_PREVNTN_ABE
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure for the management of accidental blood exposure exists.
Technical specs
CSV column name:
ABE|CD_UPD_PROC_ABE
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Vaccination against influenza
Fields
An influenza vaccination campaign for staff took place in the reference year.
Technical specs
CSV column name:
VACC_INFLZ|CD_CAMPGN_INFLZ
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Number of persons with the status of nurse, midwife or healthcare assistant, employed by the hospital as of December 31 of the reference year, who were vaccinated against influenza during that year.
Technical specs
CSV column name:
VACC_INFLZ|MS_EMPL_VACC_INFLZ
Required:
true
Validation
- Number of vaccinated employees cannot be higher than the total number of employees (error)
Number of persons with the status of nurse, midwife or healthcare assistant, employed by the hospital as of December 31 of the reference year.
Technical specs
CSV column name:
VACC_INFLZ|MS_EMPL
Required:
true
Validation
- Number of vaccinated employees cannot be higher than the total number of employees (error)
Medical devices
Fields
One of the infection control physician(s) and/or infection control nurse(s) attends the medical devices committee meetings.
Technical specs
CSV column name:
MED_DEVICE|CD_MEET_MDC
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Antibiotherapy
Fields
The infection control physician attends the antimicrobial stewardship group meetings.
Technical specs
CSV column name:
ANTBIO|CD_MEET_ANTIMICRO
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure for antibiotic prophylaxis in surgery exists.
Technical specs
CSV column name:
ANTBIO|CD_UPD_PROC_ABP
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
| Not applicable | 9 |
Not applicable: motivation.
Help
Motivation for choosing "not applicable" (For example: the hospital has no operating rooms).
Technical specs
CSV column name:
ANTBIO|TX_UPD_PROC_ABP
Only when:
Required:
true
Compliance with this procedure was subject to an audit.
Technical specs
CSV column name:
ANTBIO|CD_COMPLIA_AUDIT_ABP
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The hospital participated in the antibiotic prophylaxis in surgery audit from BAPCOC.
Technical specs
CSV column name:
ANTBIO|CD_AUDIT_SURG_ABP
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
| Not applicable | 9 |
Not applicable: motivation.
Help
Motivation for choosing "not applicable" (For example: the hospital has no operating rooms).
Technical specs
CSV column name:
ANTBIO|TX_AUDIT_SURG_ABP
Only when:
Required:
true
Infection prevention
Fields
An updated procedure for the prevention of contact/droplet/airborne transmission exists.
Technical specs
CSV column name:
INFCT_PREVNTN|CD_UPD_PROC_CDAT
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The application of these preventive measures was subject to an audit.
Technical specs
CSV column name:
INFCT_PREVNTN|CD_APP_AUDIT_CDAT
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure to prevent transmission by screening of patients who are known MDRO carriers exists.
Technical specs
CSV column name:
INFCT_PREVNTN|CD_UPD_PROC_SCRNG_MDRO
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The application of these preventive measures was subject to an audit.
Technical specs
CSV column name:
INFCT_PREVNTN|CD_APP_AUDIT_SCRNG_MDRO
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure to prevent infections related to admission of patients who are known MDRO carriers exists.
Technical specs
CSV column name:
INFCT_PREVNTN|CD_UPD_PROC_ADMI_MDRO
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
The application of these preventive measures was subject to an audit.
Technical specs
CSV column name:
INFCT_PREVNTN|CD_APP_AUDIT_ADMI_MDRO
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
A preventive approach regarding the transmission of tuberculosis exists.
Technical specs
CSV column name:
INFCT_PREVNTN|CD_APPR_TUBERC
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
A preventive approach regarding the risk of Creutzfeld Jacob disease exists.
Technical specs
CSV column name:
INFCT_PREVNTN|CD_APPR_CJD
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Disinfection
Fields
An updated procedure for the disinfection of the endoscopes exists.
Technical specs
CSV column name:
DINFCT|CD_UPD_PROC_DINFCT_ENDOSC
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
| Not applicable | 9 |
Not applicable: motivation.
Help
Motivation for choosing "not applicable" (For example: the hospital has no operating rooms).
Technical specs
CSV column name:
DINFCT|TX_UPD_PROC_DINFCT_ENDOSC
Only when:
Required:
true
An updated procedure for the disinfection of the endocavity ultrasound probes exists.
Technical specs
CSV column name:
DINFCT|CD_UPD_PROC_DINFCT_EUP
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
| Not applicable | 9 |
Not applicable: motivation.
Help
Motivation for choosing "not applicable" (For example: the hospital has no operating rooms).
Technical specs
CSV column name:
DINFCT|TX_UPD_PROC_DINFCT_EUP
Only when:
Required:
true
The application of these preventive measures was subject to an audit.
Technical specs
CSV column name:
DINFCT|CD_APP_AUDIT_DINFCT
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An approach to prevent the risk of infection related to the management of construction works exists.
Technical specs
CSV column name:
DINFCT|CD_APPR_INFCT_CONSTR
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An approach to prevent the risk of infection related to the cleaning and disinfection of surfaces and non-medical equipment exists.
Help
e.g. bed, nightstand, toilet,...
Technical specs
CSV column name:
DINFCT|CD_APPR_INFCT_SURF
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An approach to prevent the risk of infection related to the cleaning and disinfection of non-critical medical materials exists.
Help
e.g. stethoscope, blood pressure monitor, thermometer
Technical specs
CSV column name:
DINFCT|CD_APPR_INFCT_NCRIT_MAT
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
Infection control
Fields
A risk management plan with regard to the distribution of warm water for sanitary purposes exists.
Technical specs
CSV column name:
INFCT_CTRL|CD_RMGMPL_H2O
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure to prevent the risk of infection in operating rooms and rooms for interventional techniques exists.
Technical specs
CSV column name:
INFCT_CTRL|CD_UPD_PROC_OR
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
| Not applicable | 9 |
Not applicable: motivation.
Help
Motivation for choosing "not applicable" (For example: the hospital has no operating rooms).
Technical specs
CSV column name:
INFCT_CTRL|TX_UPD_PROC_OR
Only when:
Required:
true
Compliance with this procedure was subject to an audit.
Technical specs
CSV column name:
INFCT_CTRL|CD_COMPLIA_AUDIT_OR
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
An updated procedure to prevent the risk of infection in delivery rooms exists.
Technical specs
CSV column name:
INFCT_CTRL|CD_UPD_PROC_DR
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
| Not applicable | 9 |
Not applicable: motivation.
Help
Motivation for choosing "not applicable" (For example: the hospital has no operating rooms).
Technical specs
CSV column name:
INFCT_CTRL|TX_UPD_PROC_DR
Only when:
Required:
true
Compliance with this procedure was subject to an audit.
Technical specs
CSV column name:
INFCT_CTRL|CD_COMPLIA_AUDIT_DR
Only when:
Required:
true
Options
| Label | Value |
| Yes | 1 |
| No | 0 |
4 Process indicator
Total consumption of alcohol-based hand-gel this year in the care units of the hospital.
Help
Volume in litres
Technical specs
CSV column name:
MS_CONSUMP_HANDGEL
Required:
true
Total number of hospitalisation-days.
Technical specs
CSV column name:
MS_HOSPZ
Required:
true
5 Feedback
Feedback on these indicators.
Technical specs
CSV column name:
TX_FEEDBACK
Required:
false