Surveillance In Infection Control Program

By Prof. Dr. Aisha Aboul Fotouh Faculty of Medicine Ain Shams University

Prof Dr Aisha Aboul Fotouh

Definition of Surveillance
A systemic and ongoing method of data collection, presentation and analyzing then followed by dissemination of that information to those who can improve the outcome. The data concerning the distribution and determinants of a given disease or any health event.

Prof Dr Aisha Aboul Fotouh

The Surveillance Cycle

Evaluation

Planning for definition of objective

Intervention Dissemination Tools of surveillance

Analysis and interpretation

Data collection
Implementation

Prof Dr Aisha Aboul Fotouh

Key Facts for Surveillance



Surveillance should be constantly changing; has an evolutionary nature so infection control professionals must be adopted to change. Epidemiology is a population based science, surveillance is planned to study the distribution and determinants within defined population who are at risk for development of specific outcome. For surveillance there is no cook book for it so it is less important to identify a surveillance system by a particular name but is important to be well designed. So each health care organization must tailor its surveillance system to maximize utility of all health care resources and best match resources with outcome priority to achieve institutional objective.

Prof Dr Aisha Aboul Fotouh

Key Facts for Surveillance



On surveillance, data is tied to action data and reports generated must support the health care teams team effort in risk reduction in process and system improvement thus it is important for continuous quality improvement so the success of any surveillance program must be based on improving of patient care. Surveillance may be a monitoring process which likely leads to outcome i.e. indwelling catheter

Surveillance is a team approach.

Prof Dr Aisha Aboul Fotouh

Usage of Surveillance
I.

Improvement of outcomes and processors Through convincing the members of health care team of the need to implement prevention and control activities Armed with expert in infection control, the surveillance data has influential effect on clinician Through provision the providers of any service by their outcome in comparison with other groups Through monitoring of the quality indicators, e.g. clinical indicator as nosocomial infection rate by which we can define any weakness or areas of opportunities that may exist in the system . Provide base line data which directly influence health care personnel to search for mechanism to lower rate by improving the process to ir-reductable minimum . ir-

II.

Prof Dr Aisha Aboul Fotouh

Usage of Surveillance (cont.)

III.

Problem identification - Such as detection of unrecognized clusters or outbreak - Sentinel event: SSI caused by group A streptococci , or exposure T.B before isolation exposure to AIDS before diagnosis Evaluation of the control measures: If intervention activities has been implemented for purpose of interrupting the transmission of any site of infection. Continued measurement is necessary to determine the effectiveness of any intervention

IV.

Prof Dr Aisha Aboul Fotouh

Usage of Surveillance (cont.)

V.

Evaluation and reinforcement of practice: Surveillance evaluate the change in practice and the parallel change in infection rate and can reinforce the caregivers to the preventive practice which must be integrated as routine behavior e.g. recapping prevention of the needle. Education of the health care team: Educational information become more meaningful when it contains locally derived data with relevance to practice.

VI.

Prof Dr Aisha Aboul Fotouh

Usage of Surveillance (cont.)

Research VIII. For accreditation: Accrediting agencies strongly suggest presence of surveillance activity. Investigation of problems: Extra effort is IX. needed to give additional information by in depth surveillance. X. For determining outbreak threshold: doubled the baseline rate. N.B Is surveillance needed in outpatient or short course setting.
VII.

Prof Dr Aisha Aboul Fotouh

Surveillance process
I.

Choosing the event to be studied Choosing the problem - Relative frequencies - Cost of negative outcome - Potential for prevention - Priority by health care team - Community needs - Organizational mission - Available resources

Prof Dr Aisha Aboul Fotouh

Surveillance process (cont.)

II. Defining

the study population

- Ideally total population - If defined broadly i.e. heterogeneous, the rate will not be able to pinpoint the preventive measure. - If narrow i.e. homogenous, it gives restricted results.

Prof Dr Aisha Aboul Fotouh

III. Appropriate

method of measurement

Decision about rate must be in the planning process to define what type of data to be collected Ratio = a / b Rate = a / a+b x K in certain time and place Crude rate: overall rate rate: Category specific Prevalence rate:
No. of existing cases from specified interval or point of time Population at risk in the same time xK

Incidence rate:
No. of new cases of a disease Population at risk in the same time xK

Incidence density:
No. of cases during an observation period Time each person was observed totaled for all patients x 100

Adjusted rate Risk index -- Stratification

Prof Dr Aisha Aboul Fotouh

IV.

Definition of numerator: We have the CDC definition

Infection site Blood Urine Postoperative wounds Other wounds Burns Positive culture >= 5 / colonies of bacteria per 1ml 10 Pus at the incision site Presence of pus >= 6 10 organisms per 1 g of biopsied tissue; new inflammation or new pus not present on admission New sputum production with new infiltrate on chest X-ray Xnot present on admission Positive culture for pathogen or unexplained diarrhea for >= 2 days Pus at site Clinical picture Criteria for infection

Pulmonary Intestinal Skin/ IV Miscellaneous ( hepatitis, URTI, peritonitis --) --)

Prof Dr Aisha Aboul Fotouh

Surveillance process (cont.)

V.

Denominator: - Population at risk - No. of exposures i.e. No. of surgical procedures - Days risk

Prof Dr Aisha Aboul Fotouh

VI. Collection

of data

A- What data should be collected? The value of data collected vs. burden of collection and analysis demographic, clinical, laboratory and risk factors ( host and procedures). B- Who collects the data? - Active vs. Passive - Responsibilities - Quality management of collected data - Multidisciplinary collaboration

Prof Dr Aisha Aboul Fotouh

Surveillance process (cont.)

C- Timing of surveillance: - Concurrent or prospective - Retrospective surveillance - Post discharge surveillance

Prof Dr Aisha Aboul Fotouh

D- Types of surveillance Advantage

Type of surveillance
-Collect

Disadvantage
-Time

Hospital wide surveillance Periodic surveillance

(prevalence surveillance)

baseline - Identify trend -Recognize the outbreak

-Easy

consuming -Need a full time ICP

-Provide limited data -Not time consuming - Missing clusters -Gives magnitude of - Measures new +old the problem cases
-

Targeted surveillance
(for outbreak threshold)

Concentrate to high risk area e.g. VAP Defined baseline and threshold

- Data

restricted only to surveyed group - For specific objectives

Prof Dr Aisha Aboul Fotouh

E- Source of Data and Case Finding Methods

Methods
Total chart review Selected medical record Laboratory reports Kardex screening Fever chart Antibiotic Autopsy reports Readmission Risk factor based surveillance

Sensitivity
0.74 - 0.94

0.77- 0.91 0.75 - 0.94 0.09 - 0.56 0.57 0.08 0.08 0.50 0.89

Prof Dr Aisha Aboul Fotouh

F- Data collection:
Standardized form facilitate consistency It must be designated with medical record to achieve surveillance objectives - Line listing form: Contains data for many patients Gives rapid conclusion but not suitable for comprehensive surveillance for large population - Case form: Used for single case Gives detailed data for population based surveillance

Prof Dr Aisha Aboul Fotouh

Surveillance process (cont.)

VII.

Data presentation:

Computer is essential - Tabulation according to: site, pathogen, host related risk factor, therapy, procedures, risk strata e.g. birth weight - Cross tabulation: Pathogen and site - Line trend - Area map

Prof Dr Aisha Aboul Fotouh

Surveillance process (cont.)

VIII.

Evaluation and interpretation:

- Calculation of rate - Risk stratification - Standardized risk stratification for inter hospital comparison

Prof Dr Aisha Aboul Fotouh

Surveillance process (cont.)

IX.

Dissemination of data

A- Feedback is an important intervention B- Surveillance report should be behind ICC C- Methods of presentation: -Verbal or Written -Written is preferred as it is documented D- Effective message E- Timing of report

Prof Dr Aisha Aboul Fotouh

Surveillance process (cont.)

X.

Intervention and improvement activities:

- It is specially tailored for every problem ICC is very important with stakeholders as it is multidisciplinary approach - It must be documented
XI. Follow

up and surveillance:

Did the rate improve after surveillance?

Prof Dr Aisha Aboul Fotouh

Mechanism to enhance quality of surveillance data

1. 2.

3.

Training of surveillance staff must be standardized Quality control through external validation of surveillance decisions is important to ensure that definitions are being accurately applied to meet what is called gold standard This could be done by standard reviewing sample of cases. Consistency of the surveillance effort and methodologies must be maintained over a time, since the intensely of surveillance will effect the sensitivity of the system. So it is important to avoid fluctuation in the surveillance activity either by increase patients or decreased staffing.

Prof Dr Aisha Aboul Fotouh

Mechanism to enhance quality of surveillance data

4. Administrative commitment to the infection control program should be provided to support the surveillance activities. 5. Computerization: It facilitates the function of all components of surveillance and support the information system within the hospital.

Prof Dr Aisha Aboul Fotouh

Steps in outbreak investigations

1- Review existing information  2- Determine the nature, location and severity of the disease problem  3- Verify the diagnosis  4- Establish a case definition  5- Request that the laboratory saves isolates from affected patients and from suspected sources or vehicles


Prof Dr Aisha Aboul Fotouh

Steps in outbreak investigations (cont.)

   

6- Draw an epidemic curve 7- Establish the existence of an outbreak 8- Develop hypotheses 9- Test hypotheses in comparative ( casecontrol or cohort) studies 10- Provide control measures

Prof Dr Aisha Aboul Fotouh

Application of surveillance for antibiotic usage It can solve some problems associated with antibiotic usage:
1) The usage of broad-spectrum agents when restricted spectrum are as effective. 2) Treatment for long duration. 3) Treatment by intravenous route when oral therapy is effective. 4) Use of combined therapy when one is effective. 5) Inappropriate dosage for patients with chronic diseases e.g. chronic renal or hepatic dysfunction. 6) Definition of MRSA and identification of the sources of infection specially in the presence of clusters of infection.

Prof Dr Aisha Aboul Fotouh

Through surveillance we can perform drug utilization evaluation (DUEs)

Importance of (DUEs)
- We can identify the usage pattern and trend of antibiotic usage in different hospital units. - Provide base line data for usage of antibiotics. - It give feed back to Clinicians for any arising side effect. - Give information regarding emerging of resistant pathogens. - Provide data for cost containment.

Thank you