165x Filetype PDF File size 0.19 MB Source: www.apic.org
Recommended practices for surveillance: Association for Professionals in Infection Control and Epidemiology (APIC), Inc. Terrie B. Lee, RN, MS, MPH, CIC, Ona G. Montgomery, RN, MSHA, CIC, James Marx, RN, MS, CIC, Russell N. Olmsted, MPH, CIC, and William E. Scheckler, MD Surveillance in public health is defined as ‘‘the on- the frequency of adverse events such as infection or going, systematic collection, analysis, interpretation, injury. Although the goal of contemporary infection and dissemination of data regarding a health-related prevention and control programs is to eliminate HAIs, event for use in public health action to reduce morbid- epidemiologic surveillance is still required for accurate ity and mortality and to improve health.’’1 Infection quantification of events and demonstration of perfor- control professionals apply this definition to both re- mance improvement. duce and prevent health care–associated infections Althoughthereisnosingleor‘‘right’’methodofsur- (HAIs) and enhance patient safety. Surveillance, as veillance design or implementation, sound epidemio- part of infection prevention and control programs in logic principles must form the foundation of effective health care facilities, contributes to meeting the pro- systems and be understood by key participants in the gram’s overall goals, namely: (1) protect the patient; surveillance program and supported by senior man- (2) protect the health care worker, visitors, and others agement. Teamwork and collaboration across the in the health care environment; and (3) accomplish health care spectrum are important for the develop- the previous two goals in a timely, efficient, and cost- ment of surveillance plans. Rather than institute a effective manner whenever possible.2,3 ‘‘one size fits all’’ approach to surveillance, each health TheAPICfirstpublisheditsRecommendedPractices careorganizationmusttailoritssurveillancesystemsto for Surveillance in June 1998.4 This revision includes maximizeresourcesbyfocusingonpopulationcharac- updates related to changing technology and methodol- teristics, outcome priorities, and organizational objec- ogies, as well as new online resources. Demonstration tives. To ensure quality of surveillance, the following of quality health care includes documentation of out- elements must be incorporated: comesofcare.Surveillanceisacomprehensivemethod a. Awritten plan should serve as the foundation of any of measuring outcomes and related processes of care, surveillanceprogram.Theplanshouldoutlineimpor- analyzingthedata,andprovidinginformationtomem- tantgoals,objectives,andelementsofthesurveillance bers of the health care team to assist in improving process so that resources can be targeted appropri- those outcomes. Surveillance is an essential compo- ately. This is commonly integrated into a comprehen- nent of effective clinical programs designed to reduce sive infection control risk assessment process. b. Thoroughness or intensity of surveillance for an From Department of Epidemiology, Charleston Area Medical Center, areaofinterestmustbemaintainedatthesamelevel Charleston, West Virginia. overtime.Fluctuationsofasurveillanceratehaveno AddressCorrespondencetoTerrieB.Lee,RN,MS,MPH,CIC,Director, meaning unless the same level of data collection is Epidemiology&EmployeeHealth,CharlestonAreaMedicalCenter,3200 maintained.Externalratecomparisonsarenothelp- MacCorkleAvenue,Charleston, WV25304.E-mail:tleewv@msn.com. AmJInfect Control 2007;35:427-40. ful and potentially misleading unless the systems 0196-6553/$32.00 used have comparable intensity. Copyright ª 2007 by the Association for Professionals in Infection c. All the elements of surveillance should be used Control and Epidemiology, Inc. with consistency over time; this includes applica- doi:10.1016/j.ajic.2007.07.002 tion of surveillance definitions and rate calculation methods. 427 428 Vol. 35 No. 7 Lee et al d. Personnel resources need to be appropriate for the RECOMMENDEDPRACTICEI type of surveillance being performed; this includes Assessing the population trainedprofessionalswhounderstandepidemiology andsurveillance and who have access to continuing Each organization serves different types of patients professional education opportunities. who are at varied risks for health outcomes (both e. Other resources essential to surveillance include negative and positive). Development of surveillance computer support, information and technology systems should be based on evaluation of the popula- services, clerical services, and administrative under- tions of interest. Such a risk assessment is critical so standing and support to maintain a quality program. that resources can be targeted at populations who are Theuseofspecialinfectioncontrolsoftware,orself- at risk for the outcomes of greatest importance. This, formatted spreadsheets or databases can greatly in turn, enables clinicians to use surveillance informa- facilitate many aspects of the surveillance process, tion to enhance and improve care provided to those includingcompilingandmanagementofdata,statis- targeted populations. tical analysis (eg, trend and comparative analysis, stratification, significance testing), graphical presen- Practical applications tation, and report generation. 1. Obtaininformationtodescribeandunderstandpop- f. The surveillance program (including surveillance ulation characteristics. The following questions may processes and data), as part of the overall infection assist in the assessment of a patient population: prevention and control program, should be evaluated at least annually. Evaluation methods may include d What types of patients do we serve? qualitative assessments, but should also be based on d What are the most common diagnoses? quantitative changes (eg, improvements or decline in d What are our most frequently performed surgical rates). Discontinuing surveillance of outcomes and/or or other invasive procedures? processes that have remained stable and essentially d Which services or treatments are used most unchangedovertimeshouldbeconsideredtoallocate frequently? resources to address risks with higher priority. d Are there services or treatments that increase risk of infection for the patient? Thisdocumentisintendedtoassistprofessionalswho d What types of patients increase liability and/or planandconductsurveillanceprogramsaswellasthose costs for the organization? whoassurethatthereisappropriateorganizationalsup- d Does the organization’s strategic plan focus on port to accomplish appropriate surveillance. Although particular groups of patients? design of surveillance systems must be unique for each d What types of health concerns exist in the com- organization, incorporation of these seven core Recom- munity, region, or regulatory environment? mendedPractices for Surveillance provides a scientific d Which patients are at increased risk for infection frameworktoapproachsurveillanceprograms.Inaddi- or other important outcome? tion, expertise in surveillance methodologies will assist Thoughnotaddressedhere,ageneralknowledgeofrisk the infection prevention and control professional factors for infection and other outcomes is essential. whenaddressingissuesrelatedtosystemsthatperform Suchinformationshouldbeobtainedfromtheliterature inter-facilitycomparisons.(eg,publicreportingofhealth andothertrainingsources.Similarassessmentquestions care outcomesorotheraggregatedatabases.) should be forumulated for surveillance of other organi- Thepurposeofthisdocumentistoprovideaframe- zational subpopulations such as health care workers. workforthe development of epidemiologic-based sur- 2. As appropriate, use organization-specific sources veillance systems for use in health care settings; it is to obtain population information. Sources might notintendedasanindependenteducationalortraining include the following: document. The following recommendations are based on a synthesis of current experience and knowledge d Medical records ofsurveillance,aswellaspublicationsinpeer-reviewed d Financial services journals. d Information services Surveillance planning may not always proceed in d Quality/utilization management the sequential order presented here. However, organi- d Surgical database zationsshouldensurethatallofthefollowingpractices d Administrative/management reports are incorporated into each surveillance plan. These d Risk management Recommended Practices for Surveillance have been d Public health reports mostthoroughlyappliedtoHAIs,buttheyareappropri- d Community agencies ate for any health care outcome or process. d Occupational/employee health Lee et al September 2007 429 d Human resources records of stay) or positive (eg, patient satisfaction). A process d Marketing reports istheseriesofstepstakentoachieveanoutcome(eg,im- 3. Conduct population risk assessment in conjunction munization, use of patient restraints, compliance with withselectingtheoutcomeorprocess(see‘‘Selecting policies associated with a given outcome). Outcomes the outcome or process for surveillance’’ section and processes included in a surveillance plan should below)toestablish priorities for surveillance. bethosethat have the most important relevance to the population served. This selection process should occur Examples in conjunction with population assessment (see ‘‘As- sessing the population’’ section above). Decisions may 1. Hospital A is a 1500-bed tertiary care medical center bebasedonmorbidity,mortality,cost,orotherparame- offering a wide range of inpatient and outpatient ters. Legislative, regulatory, or accrediting organizations services. There are six critical care units (medical, as well as corporate or network entities may have addi- surgical, coronary,neurosurgical,pediatrics,andne- tional requirements for surveillance activities that may onatal). The open heart surgery program is one of affect the relative priority of surveillance objectives. thelargestinthecountry.Thereisalargeorthopedic surgery program and a predominant gynecology Practical applications service as well. An analysis of surgical procedures 1. Select outcomes or associated processes for surveil- data from the operating room database reveals that lance based on organizational and patient popula- coronary artery bypass graft (CABG) procedures, or- tion risk assessment. Consider the following: thopedicjointreplacements,andhysterectomiesare amongthemostcommonlyperformedsurgicalpro- d Relative frequency of the event cedures. Outpatient medical records indicate that d Cost or impact of the negative outcome, such as primary care is available in the clinic setting, with treatment costs, length of stay, functional status, large numbers of participants in both the pediatrics qualityoflife,mortality,severitymeasures,andlit- and geriatrics populations. igation and/or public relations risks 2. Hospital B is a 75-bed acute care hospital in a rural d Potential for surveillance information to contrib- setting. Medical records show that most admissions ute to prevention activities are adult patients with a variety of acute medical di- d Customer needs (eg, priorities set by the health agnoses. General surgical procedures are performed care team) by the two staff surgeons, with cholecystectomies, d Communityserved(eg,healthneedsofthepatient hysterectomies, and hernia repairs the most fre- population) quently performed. Some nursing personnel have d Organizational mission and strategic goals reported that many patients may have had indwell- d Strength of association between process and ing urinary catheters longer than necessary or with- important outcome out a clear indication for use. One health problem d Microbiology data and/or antimicrobial use noted by the local public health department is a re- findings cent increase in the incidence of tuberculosis (TB). d Regulatory or accrediting body requirements 3. A homehealthagencyprovidescaretoawiderange 2. Allocate surveillance resources by directing them ofpatients,specializinginintravascularaccess/treat- toward highest ranked priorities. ment with short-term and long-term central lines 3. Re-evaluate resulting surveillance objectives as andwithperipherallines.Thereisalsoalargenum- needed, at least annually. ber of patients with indwelling urinary catheters. Examples RECOMMENDEDPRACTICEII 1. The following infection surveillance is planned Selecting the outcome or process for a calendar year at Hospital A (see Example 1 in for surveillance ‘‘Assessing the population’’ section above): Anorganization would rarely find it feasible to con- d All patients in the intensive care unit will be moni- ductorganization-widesurveillanceforallevents.Alog- tored for two types of device- associated infec- ical method for setting surveillance priorities and tions, ventilator-associated pneumonias (VAPs), associated resource allocation is essential. The choice andcentral line–associated bloodstream infections of outcomes or processes to be measured defines the (CLABSIs). Rationale: high-risk patients, substantial surveillance that is appropriate for each measure. An opportunity for improvement, can compare with outcomeistheresultofcareorperformance.Outcomes rates most recently reported by the National Noso- maybenegative(eg, infection, injury, increased length comial Infections Surveillance/National Healthcare 430 Vol. 35 No. 7 Lee et al Safety Network (NNIS/NHSN) of the Centers for increased prevalence of TB in community, oppor- Disease Control and Prevention (CDC). tunity for early detection and intervention. d Adherence by personnel with ‘‘bundles’’ (groups d Use of indwelling urinary catheters will be moni- of evidence-based interventions) for prevention of tored among all patients. Rationale: process asso- VAPs and CLABSIs will be monitored. Rationale: ciated with infectious outcome. processes that are associated with prevention of d Immunization of appropriate patient care person- infectious outcomes. nelforhepatitisBwillbemonitored,aswillannual d Surgical site infection (SSI) surveillance will be influenzavaccinationparticipationrate.Rationale: performed on the three most common types of processes knowntopreventserious infections. surgical procedures:CABG,orthopedicjointreplace- 3. A home health company (see Example 3 in ‘‘Assess- ments, and hysterectomies. Rationale: CABG: high- ingthepopulation’’sectionabove)decidestoinclude risk patients, potential forseriousadverseoutcomes, three types of device-associated infections in the frequently occurring procedure, risk management annual surveillance plan: central line–associated concerns; joint replacements: same rationale; hys- bloodstream infections, peripheral line–associated terectomies: frequently occurring procedure. Rates bloodstream infections, and catheter-associated for comparison are available from NHSN. Also, urinary tract infections. Patients with intravascular nurses have reported a perception that there have devices will also be monitored for development of been numerous surgical site infections in patients phlebitis. Rationale: potential for improvement of undergoing hysterectomy. high-risk device-related outcomes. d Antibiotic prophylaxis will be monitored as a pro- cess measure among the same surgical popula- tions, with a focus on antibiotic delivery timing. RECOMMENDEDPRACTICEIII Rationale: process known to be associated with Using surveillance definitions preventing the outcome of SSI. d Immunizationrates will be monitored in the inpa- In any surveillance system, all data elements should tient settingsandoutpatientmedicalandpediatrics be clearly defined. This includes the outcome or pro- clinics.Forpediatrics,state-requiredchildhoodim- cess,‘‘at-risk’’ population, and risk factors. Valid defini- munizationswillbeincluded.Foradults,thefocus tions will enhance consistency, accuracy, and will be on influenza and pneumococcus vaccina- reproducibility of surveillance information. tions amonghigh-riskpopulations.Rationale:pro- cess that is known to prevent serious infections, Practical applications required information for primary care monitoring 1. Use standardized written case definitions to ensure as well as a quality indicator for the Centers for precisesurveillance.Whereavailableandapplicable, MedicareandMedicaidServices. use previously published, validated definitions. 2. The annual infection surveillance plan for Hospital Thesemaybeobtainedfromfederalagencies,regu- B(see Example 2 in ‘‘Assessing the population’’ sec- latorybodies,andprofessionalorganizations.Where tion above) will include the following components: not available, prepare written definitions to ensure intra-organization standardization. For accurate and d SSI surveillance will be performed for cholecys- valid comparisons of data, use the same definitions tectomies, hysterectomies, and hernia repairs. over time. Because the number of procedures is so low, rate 2. When historical data are used for internal compari- calculations may be needed only annually or sons or for external comparisons, ensure that the perhaps less frequently. Although the infection same definitions are used for outcomes and pro- control professional (ICP) will keep aware of SSIs, cesses and that populations are at similar risk. there is no plan to calculate infection rates for 3. If definitions are changed, be aware that such other types of infections, because infections changes compromise the comparability of rates occur too infrequently and the numbers are too over time. This information should be highlighted small to be meaningful. Rationale: focus on the whenreporting data to avoid misinterpretation. most frequent surgical procedures, can compare rates to those reported by CDC’s NNIS/NHSN Examples system. d TB skin-testing compliance rates will be moni- 1. The ICPat an acute care hospital decides to conduct tored among all staff, as well as among patients surveillance for primary bloodstream infections as- inhigh-riskpopulations.Skintestconversionrates sociated with the use of central lines in the surgical will also be followed among staff. Rationale: intensive care unit (SICU) patients. To be able to
no reviews yet
Please Login to review.