SURVEILLANCE TECHNIQUES AND METHODOLOGIES
SURVEILLANCE TECHNIQUES ANDMETHODOLOGIESEvelyn Cook, RN, CICSPICE
GOALS OF SURVEILLANCE LECTURE Describe the recommended practices forsurveillance List the elements required for an organizationsurveillance system Describe standardized definitions used forsurveillance Apply information to case studies
KEY CONCEPTS Surveillance is an essential component of aneffective infection prevention program. Should be based on sound epidemiological andstatistical principles Should be designed in accordance with currentrecommended practices and consist of defined elements Plays a critical role in identifying outbreaks, emerginginfectious disease and bioterrorist events
DEFINITIONS Continual observation of a person or group,especially one suspected of doing something illegal(Bing Dictionary) Is the monitoring of the behavior, activities, orother changing information, usually of people forthe purpose of influencing, managing, directing, orprotecting. (Wikipedia)“Local IP”
DEFINITIONS CONT’D Disease surveillance is an epidemiologic practiceby which the spread of disease, is monitored inorder to establish patterns of progression. The Healthmain role of disease surveillance is to predict, Departmentobserve, and minimize the harm causedby outbreak, epidemic, and pandemic situations, aswell as increase knowledge about which factorscontribute to such circumstances. A key part ofmodern disease surveillance is the practiceof disease case reporting.
DEFINITION CONT’D “Surveillance is a comprehensive method of measuringoutcomes and related processes of care, analyzing thedata, and providing information to members of thehealthcare team to assist in improving those outcomesand processes” ObservationMonitor behaviorEstablish patterns/trendsMeasure outcomes, processes; Analyze data; feedbackof data to improve outcomes and processes
EVOLUTION OF SURVEILLANCE PROGRAMS 1958: AHA recommended in response to outbreaks ofStaphylococcus aureus infections in hospitals. 1960’s: CDC recommended hospital base programs includesurveillance 1976: TJC first included infection surveillance, preventionand control standards in its accreditation manual
THE SENIC PROJECT. STUDY ON THE EFFICACY OFNOSOCOMIAL INFECTION CONTROL. CDC undertook in 1974 Three primary objectives: 1) to determine whether (and, if so, to what degree) theimplementation of infection surveillance and controlprograms (ISCPs) has lowered the rate of nosocomialinfection, 2) to describe the current status of ISCPs and infectionrates, and 3) to demonstrate the relationships amongcharacteristics of hospitals and patients, components ofISCPs, and changes in the infection rate.
SENIC FINDINGS SENIC found that hospitals reduced theirnosocomial infection rates by approximately 32% iftheir infection surveillance and control programincluded four components: 1) appropriate emphases on surveillance activities andvigorous control efforts, 2) at least one full-time infection-control practitioner per250 beds, 3) a trained hospital epidemiologist, and 4) for surgical wound infections (SWIs), feedback ofwound infection rates to practicing surgeons.
RATIONAL FOR CONDUCTINGSURVEILLANCE Determine baseline (endemic) Early detection of epidemics (adverse outcomes) Assess the effectiveness of prevention and control measures Monitor the occurrence of adverse outcomes to identify riskfactors Observe practices to promote compliance Target performance improvement Compliance with regulations and accrediting agencies (includinghealth department) Monitor bioterrorism events Provide information for the education of healthcare personnelAPIC Text, 2015
NEW DEVELOPMENTS IN HAI SURVEILLANCE[PAST DECADE] Continuing shift from acute care to ambulatory, LTCFDecreased LOS across continuum of careEmerging and reemerging infectious diseasesBioterroism and syndromic surveillanceUse of surveillance data to monitor non-infectiouseventsActive surveillance culturingCulture change promotes moving beyondbenchmarking and aiming for zero HAIs
NATIONAL HEALTHCARE SAFETYNETWORK (NHSN) NHSN is an internet-based surveillance systemthat integrates the surveillance systemspreviously managed separately in the Division ofHealthcare Quality Promotion (DHQP) at CDC National Nosocomial Infections Surveillance (NNIS) system Dialysis Surveillance Network (DSN) National Surveillance System for Healthcare Workers (NaSH)
PURPOSES OF NHSNORIGINAL Collect data from a sample of US healthcarefacilities to permit valid estimation of the magnitude of adverse events among patients and healthcarepersonnel adherence to practices known to be associated with prevention ofhealthcare-associated infections (HAI) Analyze and report collected data to permitrecognition of trends
PURPOSES OF NHSN Provide facilities with risk-adjusted data that canbe used for inter-facility comparisons and localquality improvement activities Assist facilities in developing surveillance andanalysis methods that permit timely recognition ofpatient and healthcare personnel safety problemsand prompt intervention with appropriatemeasures Conduct collaborative research studies withmembers
PURPOSES OF NHSN“ONGOING” Facilities that participate in certain reporting programsoperated by the Centers for Medicare and MedicaidServices (CMS) do so through use of NHSN. Furthermore, some U.S. states use NHSN as a means forhealthcare facilities to submit data on healthcareassociated infections (HAIs) mandated through theirspecific state legislation.
THE ESSENTIALS OF SURVEILLANCE Know the protocol/criteria Consistently apply the criteria Report events meeting criteria; exclude those that don’t Failure to do so: Breach of NHSN Rules of Behavior Decreased usefulness of national comparative data Unfair comparisons between facilities Possible validation discrepancies Potential impact of CMS Inpatient quality Reporting score and facilityreimbursement Concerns about the criteria should be sent to NHSN-NOTaddressed by non-reporting of events or facility adjudicationThe Basics of NHSN Patient Safety Component Surveillance and Updates for 2017: Kathy Allen-Bridson
NHSN ComponentsPatient SafetyDevice-associated moduleProcedure-associatedmoduleAntimicrobial Use andResistance ModuleMDRO/CDI ModuleHCP Safety OP DialysisLTCFBBF ExposureMDRO/C diffLabIDInfluenza s
PATIENT SAFETY COMPONENT MODULES Device-associated CLABSI – Central line-associated bloodstream infection CLIP – Central line insertion practices VAE – Ventilator-associated events (adult locations only) VAP – Ventilator-associated pneumonia (in pediatriclocations (in-plan or off-plan), or NICU and adultlocations (off-plan) CAUTI – Catheter-associated urinary tract infection Procedure-associated SSI
PATIENT SAFETY COMPONENT MODULES Antimicrobial Use and Resistance (AUR) The primary objective of the Antimicrobial Use option is to facilitate riskadjusted inter- and intra-facility benchmarking of antimicrobial usage. A secondary objective is to evaluate trends of antimicrobial usage over time atthe facility and national levels
PATIENT SAFETY COMPONENT MODULES Choices for Multidrug resistant organism (MDRO) and CDIModule: LabID Event : (MRSA & C difficile) Infection Surveillance Prevention Process Measures Active Surveillance Testing
DATA COLLECTION AND REPORTING REQUIREMENTSFOR PATIENT SAFETY COMPONENT1. Submit a Monthly Reporting Plan to inform CDCwhich, if any, of the patient safety modules will beused for that month.2. Adhere to the selected module’s protocol(s)exactly as described in the NHSN Manual PatientSafety Component Protocol3. Use surveillance methodology as described in theProtocol
DATA COLLECTION AND REPORTING REQUIREMENTSFOR PATIENT SAFETY COMPONENT4.5.6.7.8.Report events and appropriate summary or denominatordata indicated on the Plan to CDC within 30 days of the endof the monthSubmit data for at least one module for a minimum of 6months of the calendar yearComplete an annual survey for your facilityPass quality control acceptance checks that assess the datafor completeness and accuracy.Agree to report to state health authorities adverse eventoutbreaks identified in the facility by the surveillance systemand about which you are contacted by CDC.
TYPES OF SURVEILLANCE Total (or Whole) House Surveillance All HAIs are monitored in the entire population Calculate rates for specific population (not anoverall facility wide rate) Targeted Surveillance Particular care units Infections related to medical devices Organisms of epidemiological importance Combination Surveillance Strategy Most use a combination and monitor targeted eventsthat occur in defined populations while concurrentlymonitoring select HAIs and laboratory reports fromhouse-wide locationsExamples might be MRSA and C difficile house wide but CAUTIs inthe ICU only.
SURVEILLANCE METHODS *Results with MS versus ES (HAIs inICU) were: Sensitivity 40% vs 87% Specificity 94% vs 99%*Effectiveness of an automated surveillance system for intensive careunit-acquired infections: Vienna , Austria; 2006-2007
APIC POSITION PAPER: THE IMPORTANCE OF SURVEILLANCETECHNOLOGIES IN THEPREVENTION OF HEALTHCARE-ASSOCIATED INFECTIONS (HAIS) Streamline and facilitate efficient review of relevant data, promoting rapid identification of sentinel events and detectionof outbreaksExpand and better define the scope of infection preventionactivitiesReduce infection prevention department time spent onsurveillance and clerical tasksImprove response to public health issuesRegulatory complianceFinancial performancePotential to enhance antibiotic stewardship programs
RECOMMENDED PRACTICES FORSURVEILLANCEI.II.ICRAAssess the populationSelect the outcome or process for surveillanceand determine the time periodICRAIII. Use surveillance definitionsIV. Collect surveillance dataV.Calculate and analyze infection ratesVI.Apply risk stratification methodologyVII. Report and use surveillance informationVIII. Validate surveillance methodologies and findings
*Note: “In-plan” surveillance means that the facility hascommitted to following the NHSN surveillance protocol,in its entirety, for that particular event, as shown in thefacility’s NHSN monthly reporting plan. “Off-plan”surveillance is surveillance that is done because a facilityhas decided to track a particular event for internal use.Data that are entered into NHSN “off-plan” are notincluded in NSHN annual reports or other NHSNpublications. A facility makes no commitment to followthe NHSN protocol for “off-plan” events.
USING SURVEILLANCE DEFINITIONS Define clearly all data elements outcome or process “at risk” population risk factors Use standardized written case definition (These aresurveillance definitions and not clinicaldefinitions!!!!!) If definition (CDC-NHSN) change, highlight inreports (remember mandatory reporting)Others may be trained to screen data sources for these infections,but the IP must make the final determination. (NHSN)
Infection Window PeriodNADate of EventYesPOANAHAINARepeat Infection Time PeriodNASecondary BSI AttributionPeriod**See SSI specific guidanceLabIDVAENot ApplicableSSINot ApplicableKEY TERMS
KEY TERMS NHSN Infection Window Period: Defined as the 7-days during which all site-specificinfection criteria must be met. It includes the day the firstpositive diagnostic test that is an element of the sitespecific infection criterion, was obtained, the 3 calendardays before and the 3 calendar days after. For site-specific infection criteria that do not include adiagnostic test, the first documented localized sign orsymptom that is an element of NHSN infection criterionshould be use define the window Date of Event: The date the first element used to meet an NHSN site-specific infection criterion occurs for the first time withinthe seven-day infection window period
INFECTION WINDOW PERIOD Diagnostic test examples* Laboratory specimen collection Imaging test Procedure or exam Physician diagnosis Initiation of treatment Localized sign or symptom examples: Diarrhea Site specific pain Purulent exudateIf there is more than one use the most localizing test result, e.g., if trying to determine MBILCBI, use the blood culture as opposed to ANC level
KEY TERMS Date of Event (DOE) The date the first element used tomeet an NHSN site-specificinfection criterion occurs for thefirst time within the seven-dayinfection window periodNote: The element MAY have been presentbefore the infection window period
KEY TERMS Present on Admission (POA) When the date of “event” occurs during the POA timeperiod. Defined as the day of admission to an inpatientlocation (calendar day 1), the 2 days before admission,and the calendar day after admission.Hospital DayDate of EventClassification2 days before admitHospital Day 1POA1 day before admitHospital Day 1POAAdmission (Day 1)Hospital Day 1POADay 2Hospital Day 2POADay 3Hospital Day 3HAIDay 4Hospital Day 4HAIDay 5Hospital Day 5HAI
PRESENT ON ADMISSION CONT’Important Acceptable documentation: Patient-reported signs or symptoms documented in themedical record by a healthcare professional. Physician diagnosis can be accepted only whenphysician diagnosis is an element of the specificinfection criteria Infections in newborns with date of event on hospitalday 1 or day 2 are considered POA. Day 3 or after areHAIs, includes acquired transplacentally or as a resultfrom passage through the birth canal (Group B strep)
KEY TERMS Healthcare-associated Infection (HAI) The date of event occurs on or after the 3rd calendar day of admission to aninpatient location where day of admission is calendar day1 Repeat Infection Timeframe (RIT) A 14-day timeframe during which no new infections of the same type arereported. The date of event is Day 1 of the 14 day RIT. Additional pathogens recovered during the RIT from the same type ofinfection are added to the event. Applies during a patient’s single admission including the day of discharge andthe day after. May have negative cultures during RIT Do not change device-association determination during RIT(SUTI identified, foley placed and while still in RIT meets definition for CAUTI.Add pathogen to initial event and do not change the SUTI to CAUTI )
KEY TERMS Secondary BSI Attribution Period: Is the period in which a positive blood culture must becollected to be considered as a secondary bloodstreaminfection to a primary site infection This period includes the Infection Window Periodcombined with the Repeat Infection Timeframe (RIT). Itis 14-17 days in length depending upon the date ofevent. For SSI surveillance a 17 day period that includes thedate of SSI event 3 days prior and 13 days after, is stillused to attribute a BSI as secondary to an SSI
Hospital DayBSIRITInfection WindowInfection Window123Fever 38.0 C4Urine culture 100,000 cfu/ml K. pneumonia5678910Blood Culture; K. pneumonia/YeastBlood Culture: K. pneumonia/Yeast1112131415161718192021222324UTI & Secondary BSIwith K. pneumoniaPrimary BSI withYeastRIT
KEY TERMS Transfer Rule: If the date of event (not all elements) is on the date of transfer ordischarge or the next day, the infection is attributed to the transferring,discharge location. Vital Signs: For fever use the temperature documented in the patient’smedical record. If a specific value for a vital sign is not stated in a CDC/NHSN HAIdefinition criterion, (hypotension) the facility should use the vitalsign parameters as stated in its policies and procedures for clinicalpractices.
TIDBITS OF INTEREST Additional pathogens recovered during the RIT from thesame type of infection are added to the event Example: SUTI with E. coli; during RIT SUTI with S. aureus; add S. aureusto initial event BSI pathogens may be assigned to more than oneinfection source at the same time Example: SUTI and IAB In instances where a patient has been transferred tomore than one location on the date of an infection, orthe day before, attribute the infection to the firstlocation in which the patient was housed the day beforethe infection’s date of event Example: 3/22: Unit A 3/23: Unit A, Unit B, Unit C 3/24: Unit C, Unit D(Definition of CAUTI met). Assign to Unit A
CLINICAL DISAGREEMENT?Surveillance Definitions Clinical DiagnosisPurposeIdentify trends within apopulation forpreventionIdentify disease in, andtreatment for,individual patientsComponentsLimited predetermineddata elementsAll diagnosticinformation availableClinical JudgmentExcluded if possibleValuedBottom Line: At times clinical judgment and surveillancedeterminations will not match. Surveillance determinationsalways “trump” in epidemiologic surveillance
COLLECTING SURVEILLANCE DATA Train personnel in data collection methods Develop a data collection form to fit the surveillance objectiveDetermine the appropriate approach to surveillanceconcurrent (prospective) and/or retrospectiveIncorporate post-discharge surveillance for certainoutcomesCollect data from a variety of sources (communicationwith caregivers)Be aware that passively obtained data may be biased
ORGANIZATION-SPECIFIC SOURCES OFPOPULATION INFORMATION Medical recordsFinancial servicesQuality/utilization managementSurgical databaseAdministrative/management reportsRisk managementPublic health reportsCommunity agenciesOccupational HealthHuman resources records
CALCULATING AND ANALYZINGSURVEILLANCE RATES How do you want to express surveillance information: Standardized Infection Ratios (SIRs) [observed/predicted] Rates [number of infections/number at risk] X a variable Raw numbers Use appropriate calculations Be consistent with methodology Surveillance intensity Accuracy of case and population of definitions All aspects of surveillance remains the same
WHY ANALYZE? Cover the basics: How many HAIs? Rate and DU ratio Over what period of time? Interpret the statistical results P-value Percentile Highlight successes or pitfalls. Which locations experienced 0 HAIs? Trends- have rates gone up or down If a goal is set how is the progress?Slide Acknowledgement: Maggie Dudeck, MPH, CIC, Epidemiologist NHSN Training Course
Why Analyze? Supplement the data What were the organisms identified? Any trends? What interventions have started during the time period? Changes in staff or types of patients? Any external (or internal) validation programs take place during thetime period Has surveillance methodologies changed (enhanced knowledge ondefinitions for example) Look ahead What are the plans to lower rates, or maintain low rates?
WHY ANALYZE?IN SUMMARY Help facilitate internal validation activities and helpensure accuracy Inform prioritization and success of preventionactivities Data entered into NHSN may be used by: CDC,CMS, State Health Department, special studygroups (HENs) At the end of the day, these are YOUR data-youshould know your data better than anyone else.Slide Acknowledgement: Maggie Dudeck, MPH, CIC, Epidemiologist NHSN Training Course
APPLYING RISK STRATIFICATIONMETHODOLOGY Foster understanding and acceptance by recipientsof the data Explain how the data has been stratified by risk Allows comparisons to be made Facilitate validity of interventionsMy Patientsare sicker
APPLYING RISK STRATIFICATIONMETHODOLOGY Determine to what extent the methods have beenvalidated Ascertain if relevant stratification methods arerecommended by key organizations (CDC/NHSN) If no validated methods are available obtainbiostatistical or epidemiologic assistance. Forsome rates, risk stratification may not be possible Be sure subpopulations large enough to bestatistically meaningful
NHSN 2006-2008 SUMMARY:CLABSI IN LEVEL III NICUSCentral line-associated BSI rateBirthWeightCentralline days 750 g751-1000
“In-plan” surveillance means that the facility has committed to following the NHSN surveillance protocol, in its entirety, for that particular event, as shown in the facility’s NHSN monthly reporting plan. “Off -plan” surveillance is surveillance that is done because a facility has decided to track a particular event for internal use.
1.2. Indicator-Based Surveillance (IBS) and Event-Based Surveillance (EBS) Approaches Used to Detect Diseases, Conditions and Events 52 1.3. Standard Case Definitions 52 1.4 Establish Event-Based Surveillance (EBS) at all levels 57 1.5 Update LGA Procedures for Surveillance and Response 58 1.6 Role of the laboratory in surveillance and response 61
Electronic Integrated Disease Surveillance System supports different types of surveillance: passive surveillance (case-based and aggregate) is available for human and veterinary diseases, active surveillance is supported for veterinary disease, vector surveillance is planned to be released in the next version.
Planned Methodologies vs. Agile Methodologies 27 Fig. 8. The complexity of design for future. Fig. 9. The complexity of design for today. If a difficult design problem is encountered, agile methodologies recommend the immediate creation of an operational prototype of that portion of the d
followed by a response when required. It is this element of decision and timely response based on . endemic and non -infectious diseases under surveillance. Surveillance in Human and Animal Public Health Sectors, and Integrated Surveillance The term 'surveillance' is used differently in veterinary and human public health literature, and .
Alike for NCDs, surveillance is crucial for CDS control. There are over 50 diseases, such as hepatitis A, B and C, cholera, HIV, and smallpox, on the list of diseases under epidemiological surveillance in the EU32. For CDS, surveillance takes the form of epidemiological surveillance, _ whereas for NCDs public health surveillance _ is important.
The Air Route Surveillance Radar Model 4 (ARSR-4) is a state-of-the-art, three-dimensional, long-range radar. The . 7 Surveillance Detection 4 .1. 8 Primary False Alarm Rate 4.1.9 Surveillance Resolution 4 .1.1 0 Surveillance Accuracy 4 .1.11 Beacon Target Processor Performance
Network (NHSN) NHSN is an internet‐based surveillance system that integrates the surveillance systems previously managed separately in the Division of Healthcare Quality Promotion (DHQP) at CDC –National Nosocomial Infections Surveillance (NNIS) system –Dialysis Surveillance Network (DSN)
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