A WEB-BASED SYSTEM TO REDUCE THE NOSOCOMIAL

INFECTION IMPACT IN HEALTCARE UNITS

Hugo Rigor, Jos´e Machado, Ant´onio Abelha, Jos´eNeves

Departamento de Inform´atica, Universidade do Minho, Campus de Gualtar, Braga, Portugal

Carlos Alberto

Centro Hospitalar do Porto, Porto, Portugal

Keywords:

Web Engineering, System Integration, Databases.

Abstract:

The nosocomial infection has a critical impact on the mortality and morbidity of the patients in healthcare units,

especially in intensive care units, and has been studied in order to be mitigated. The registration of information

about this phenomenon in databases is, more and more, a reality, turning viable the representation of this

information through mathematical formalisms that, conjugated with the application of Artiﬁcial Intelligence

techniques, will allow the discovery of knowledge related with the critical factors, processes and infectious

agents. The ultimate goal has been to construct a web-based computational tool to automate the registration

process to support the clinical body work, monitoring the performance and identifying the procedures that can

be implemented in order to reduce the impact of the infections.

1 INTRODUCTION

Medicine has been for some years a very attractive

domain for Computer Science (CS) researchers, in

general. There is a great potential for information

automation, and a lot remains to be done. Med-

ical Informatics (MI) is indeed an issue of study in

which Medicine and Computing overlap. Another

reason for this increasing interest was costs. Today’s

strained health-care economics makes it necessary for

expensive resources to be efﬁciently managed. CS

researchers have long used Medicine to elaborate on

their own work. The ﬁeld is probably one of the most

knowledgeintensive ones, loadedwith human reason-

ing, with most of the procedure relying exclusively

on the clinical experts. This makes health-care a per-

fect target for CS, since conventional systems are nat-

urally bounded by their lack of rich knowledge rep-

resentation and proof schemes. On the other hand,

MI Systems have to be addressed in terms of a wide

variety of heterogeneous distributed systems speak-

ing different languages, integrating medical equip-

ment and customized by several companies, which

in turn were developed by people aiming at different

goals. This lead us to consider the solution to a par-

ticular problem, to be part of an integration process of

different sources of information, using different pro-

tocols, in terms of an Agency for the Integration, Dif-

fusion and Archive (AIDA) (Figure 1) of medical in-

formation, and the Electronic Medical Record (EMR)

software (in Portuguese referred as PCE - Processo

Cl´ınico Electr´onico), bringing to the healthcare arena

new methodologies for problem solving, computa-

tional models, technologies and tools, using ambient

intelligence (Removed for blind review). The homo-

geneity of clinical, medical and administrative sys-

tems is not possible due to ﬁnancial and technical re-

strictions, as well as functional needs. The solution

is to integrate, diffuse and archive this information

under a dynamic framework, in order to share this

knowledge with every information system that needs

it. Indeed, to build systems for real health care en-

vironments, the infrastructure must meet a range of

basic requirements with respect to security, reliabil-

ity and scaling. With access granted to Clinical and

Historical Databases, agent technology may provide

answers to those who give assistance to patients with

a maximum of quality and medical evidence (Maes,

1995).

264

Rigor H., Machado J., Abelha A., Neves J. and Alberto C. (2008).

A WEB-BASED SYSTEM TO REDUCE THE NOSOCOMIAL INFECTION IMPACT IN HEALTCARE UNITS.

In Proceedings of the Four th Inter national Conference on Web Information Systems and Technologies, pages 264-268

DOI: 10.5220/0001522602640268

 SciTePress

Figure 1: AIDA.

2 AGENT ORIENTED

PROGRAMMING

The traditional programming languages do not sup-

port the description of certain types of behaviour

which usually involves computational agents (Weiss,

1999). In genesis, systems that incorporate those

functionalities have a multi-layer architecture, evolve

from esoteric software sub-systems, network proto-

cols, and the like. An agent must be able to manage

its knowledge, beliefs, desires, intentions, goals and

values ((Analide et al., 2006)). It may be able also to

plan, receive information or instructions, or react to

environment stimulus. It may communicate with oth-

ers agents, share knowledge and beliefs, and respond

to other agents upon request. It may cooperate for

diagnosing errors or information faults in its knowl-

edge bases, sharing resources, avoiding undesirable

interferences or joining efforts in order to revisit the

knowledge bases of its own and of its peers, in or-

der to reach common goals (Machado et al. 2006).

Agents exchange messages which are well-formed

formulae of the communication language, performing

acts or communicative actions ((Bradshaw, 1997)).

Agents in a healthcare facility conﬁgure applications

or utilities that collect information about the assets

in the organization ((Alves et al., 2005)). Once that

information has been collected it can be posted di-

rectly to other entities (e.g. a physician), a server,

saved to a ﬁle, emailed to someone to be handled

at a later date or sent using HL7 (Health Level 7)

(http://www.hl7.org). Indeed, in a hospital, the col-

lection of vast amounts of medical data will not only

support the requirements of archiving, but also pro-

vide a platform for the application of data mining and

knowledge discovery techniques to determine possi-

ble medical trends and the real data to support ed-

ucational training. Knowledge discovery techniques

can be applied to identify pathologies and disease

trends. The data can also be used for educational

and training purposes; unique cases can be identi-

ﬁed and used to advise practitioners. This may lead

to one’s goal of Ambient Intelligence at Health Care

Units at our doorstep (Costa et al., 2007) (Abelha

et al., 2007). HL7 plays an essential role in ex-

tending the interoperability for the development of

health information exchange, in the standardizationof

XML medical document structures and in the speciﬁ-

cation of robust vocabulary deﬁnitions for use in clin-

ical messages and documents (e.g. SNOMED CT)

(http://www.ihtsdo.org/) enabling functional speciﬁ-

cations for the EMR.

3 THE ELECTRONIC MEDICAL

RECORD

The Electronic Medical Record (EMR) is a core ap-

plication which covers horizontally the health care

unit and makes possible a transverse analysis of

medical records along the services, units or treated

pathologies, bringing to the healthcare arena new

methodologies for problem solving, computational

models, technologies and tools. One aims to develop

a comprehensive, structured approach to EMR devel-

opment and analysis. Indeed, this paper will thrash

out the inner features of intelligent agents to be used

in the EMR, in the context of the Telemedical Infor-

mation Society, a step in the direction of Intelligent

Health Care Units ((Hendler, 1996)). The process

to collect data comes from Problem Oriented Med-

ical Record (POMR) method ((Weed, 1969)). This is

a format for clinical recording consisting of a prob-

lem list, a database including the patient history with

physical examination and clinical ﬁndings, diagnos-

tic, therapeutic and educational plans ((Machado and

Alves, 2005) and a daily SOAP (Subjective, Objec-

tive, Assessment and Plan) progress note ((of Medi-

cine, 1991)). The problem list serves as an index for

the reader, each problem being followed through until

resolution. This system widely inﬂuences note keep-

ing by recognizing the ﬁve different phases of the de-

cision making process, i.e. data collection, problem

speciﬁcation, devising a management plan, review-

ing the situation and revising the plan if necessary.

One’s goal is to replace hard documents by electronic

ones, increasing data processing and reducing time

and costs. The patient assistance will be more effec-

tive, faster and the quality of service will be improved

((Machado et al., 2006)). The system uses freeware

tools or software database packages which licenses

belong to the Portuguese Health Ministry (e.g. Or-

acle software). Messages are sent by agents using

XML or HL7. According to the ontology, messages

are processed, integrated and archived in large data-

bases. The ontology is deﬁned by the administrators

and can be managed using web tools. The ”intelli-

A WEB-BASED SYSTEM TO REDUCE THE NOSOCOMIAL INFECTION IMPACT IN HEALTCARE UNITS

265

gence” of the system as a whole arises from the inter-

actions among all the system’s components. The in-

terfaces are based on Web-related front-ends, query-

ing or managing the data warehouse. Such an ap-

proach can provide decision support. A context de-

pendent formalism has been used to specify the AIDA

system incorporatingfacilities such as abstraction, en-

capsulation and hierarchy, in order to deﬁne the sys-

tem components or agents; the socialization process,

at the agent level and the multi-agent level, following

other possible way of aggregation and cooperation;

the coordination procedure at the agent level; and the

global system behaviour. The data can also be used

for educational and training purposes because maybe

one of the unique cases can be identiﬁed and used in

expert system like applications to advise practitioners

((Analide et al., 2006)). An screen view is shown in

Figure 2.

Figure 2: Procedure Registration in the EMR.

4 A WEB-BASED SYSTEM FOR

THE NOSOCOMIAL

INFECTION REGISTRATION

Despite the advancements in the area of the health

care, every year around one hundred thousand pa-

tients contract an infection at the hospital environ-

ment and more than ten thousand die in consequence

of these infections. Beyond the morbidity and con-

siderable mortality, the hospital infection provokes a

considerable increase of costs with trials of diagnosis,

of therapy and with the increaseof the time of hospital

admission.

The hospital or nosocomial infection is an infec-

tion that is notpresent at the momentof patient admis-

sion to the hospital. It can be provoked by internal or

external agents to the patient. Some of the factors that

prepare a patient to the development of a nosocomial

infection are directly related with the age, the state of

his immunity, the use of antibiotherapy, the time of

hospitalization, the techniques of diagnosis, among

others. The dynamics and the hospital environment

provide, on the other hand, diverse potential foci of

infection as the patients, the visits, the personnels, the

equipment, the installations, the environment, the in-

vasive devices, etc. All these factors are potentiated

when the patients are at Intensive Care Units, where

the problem of the nosocomial infectionhas the great-

est impact inside the Hospital environment.

The existence of scientiﬁc studies and guidelines,

such as norms to control the infection and consensus

for the diagnosis and handling of the infection, con-

tribute for a deeper understandingand diffusion of the

phenomena associated with the infections, in terms

of its prevention, diagnosis and handling. However,

despite such advancements, an efﬁcient diagnosis on

time, as well as the decision about the handling or

therapeutic, is in itself based on the empirical knowl-

edge of each professional of health. Frequently, the

inherent information concerned with the process is

not analyzed, and the results are not registered in sys-

tematized and adequate formats to a future process-

ing. The monitorization assumes, therefore, an im-

portant role in the course of this trial, once it would

permit to collect helpful and valid information for the

creation of models to support the diagnosis and the

medical decision process.

In the area of the Clinical Information Systems,

we must highlight the EMR and the Laboratory In-

formation System, as part of the platform AIDA that

is today a reality within the Hospital Geral de Santo

Ant´onio (HGSA), that has acted in collaboration with

the University of the Minho. It makes possible to col-

lect in real time data from laboratory trials, patient

and clinical information (e.g., medical images).

The making of data or knowledge bases with lab-

oratory and clinical information, enabled with AIDA,

complemented with information about the diagnosis

and the trial decisions, allow for the Knowledge Dis-

covery and Date Mining techniques in use, leading to

the induction of formal models more adjusted to the

patient proﬁles, and to the admission context.

5 THE IMPLEMENTATION

5.1 Preamble

The implementation plan of the registration system

for infection control in HGSA’s Intensive Care Unit

(ICU), emerged from the necessity of such unit of

monitorizing and accessing quality of health care pro-

vided. In order to accomplish the proposed task, it

was fundamental to acquire speciﬁc knowledge re-

lated with epidemiologic vigilance. Since there was

WEBIST 2008 - International Conference on Web Information Systems and Technologies

266

no institutionalized pattern for structuring the registry

form, operational parameters selection was performed

in three separate ways:

• Discussion sessions with the ICU clinical team;

• Bibliographic research;

• Operational ”catch up” with similar initiatives in

other clinical facilities.

Since HGSA is also engaged in taking

part in Helics III project (see http:helics.univ-

lyon1.fraboutHELICSIII.htm), it was of major

importance to maintain the compatibility between the

selected terminologies. The unique symbiosis pro-

vided by the conceptual approach behind the EMR at

HGSA, granted enormous easiness in implementing

the referred system. It utilizes XML as an integration

media, built on top of a relational database. This

way, realization itself was not the hardest task. It

uses a simple xml skeleton which contains speciﬁc

formatting parameters to be interpreted by an external

application or viewer. Different combinations of

GUI Widgets can be used like combo and check

boxes, labels, text ﬁelds, etc. This provided unique

ﬂexibility to the structure, while still maintaining

a familiar user interface for the clinician. Such

approach has also allowed restricting possible choice

values, enabling data uniformity and, consequently,

the accurate storage methodology in order to offer

useful or meaningful information for comparative

and statistical studies.

Due to the extent of the covered clinical parame-

ters, it was decided to divide the main structure into

two separate systems:

• The General Record;

• The MRB (Multiresistant bacteria) Individual

Record.

5.2 General Record for the NI Control

As the system was planed in order to follow patient’s

ICU internment, record ﬁeld line up and arrangement

were chosen following clinician’s own registry order.

The ﬁrst part of the registry contains information re-

lated with patient’s internment like origin, possibility

of infection’s presence already at admission, previ-

ous hospitalization, antibiotic therapy, etc. All data

already registered and available through EMR is au-

tomatically retrieved as a mean to avoid information

redundancy.

As described above, there was constantly the con-

cern to reduce record subjectivity to a minimum, re-

straining, when feasible, the clinical registry to a de-

ﬁned set of possible values.

The second part of the form covers clinical ar-

guments that are registered during the ﬁrst days of

internment like the SAPS II ((Gall et al., 1993))

and Glasgow indexes, imunodepression subsistence,

trauma, etc. Lastly, the rest of the structure accounts

for controlling the use of invasive devices (intubation,

central venous catheter, urinary catheter) and inci-

dence of infection. In addition to the usual recording

of ﬁrst device application, the structure can store se-

quent similar proceduresfor future data mininganaly-

sis. It also previews simple colonization recording. In

terms of infection, the main sites have been covered

(urinary infections, surgical site infections, nosoco-

mial pneumonia and nosocomial bacteraemia). All

intermediary registries for each infection were para-

meterized under Helics III speciﬁcations so that maxi-

mum compatibility could be provided,foreseeingdata

sharing with European common database initiative

(Helics III) (Figure 3).

Figure 3: General Record for the NI control.

A WEB-BASED SYSTEM TO REDUCE THE NOSOCOMIAL INFECTION IMPACT IN HEALTCARE UNITS

267

5.3 The Registry for MRB Control

Antibiotic resistance stands for the ability of a mi-

croorganism to withstand the effects of an antibiotic.

This is recurrently accomplished via natural selec-

tion through random mutation and can be hastened

by a deﬁcient politic for antibiotic usage. In order

to minimize this serious issue, an electronic record

form was created so that antibiotic resistance of sim-

ilar pathogens could be compared through time. This

way, speciﬁc data can be compared in order to rethink

antibiotic application actions. A scale of four possible

valueswas chosen for antibiotic resistance categoriza-

tion (Sensible, Intermediary, Resistent and unknown),

embedded into a XML format.

The structure also permits recording of some spe-

ciﬁc recognition methods like Screening or CMI (E-

test), used in VRSA (Vancomycin-resistant Staphylo-

coccus aureus) detection.

6 CONCLUSIONS

Future work will consider the knowledge discov-

ery about the nosocomial infections, on the basis of

guidelines, consensus, refereed articles, and infor-

mation registered on the EMR, crossing these data

with the complementarymeans of diagnosis - analytic

and, when applicable, imagiological; inducing patient

models for the early detection of nosocomial infec-

tions, with high acuteness and more adjusted to the

patients and to the environmentof the healthcare unit;

prompting models for the process of decision mak-

ing, and to a better selection of handlings. On the

other hand, we also intend to specify, to develop and

to implement a data processing computational system

starting from an online structured and systematized

recording of information about the nosocomial infec-

tion, enabling the recording of the diagnosis that were

effectively done, the register of the ﬂat therapeutic

being prescribe, the interoperation between the lab-

oratory systems and the clinical information ones and

the implementation of prevention systems and, ac-

cordingly, of programs to improve and to measure the

quality of service.

ACKNOWLEDGEMENTS

We are thankful to the Hospital Geral de Santo

Ant´onio (HGSA), in Oporto, Portugal, for their help

to the analysis and development of the EMR system

referred to above, which is now being largely used in

their premises.

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