Surveillance is not a word regularly used in healthcare facilities. Even many experienced healthcare professionals are not aware that it is a long-established practice and critical daily task in the prevention and control of infectious diseases. Infection prevention and control professionals gather, sort and analyze patient reports to determine which have infections to order to control their spread to others.
However the prevention of these infections in the first place is the desired goal. Extensive "sleuthing" has been required to find the cause of the disease (microbe), how it infects a patient, how it is spread to others, what needs to be done to eliminate it and prevent its return. This is accomplished by painstaking review of laboratory results, patient charts and other medical records.
How do they get this information? Not quickly. They start with a core requirement of microbiology lab results from all admitted patients. In a typical 300 bed hospital, this could easily be several hundred pages of paper daily. Given significant labor constraints, these reports, in various phases of completion, are reviewed for obvious problems first.
Examples include any patients growing a pathogen — a microbe which is known to cause an infection, e.g. the cause of tuberculosis or influenza. Or, more typically seen in a healthcare acquired infection, a patient with a microbe growing where there should be none, e.g. in the blood or in a surgical site. Or, worse case scenario, an infectious disease outbreak. i.e. multiple patients infected with the same organism over a brief time.
The infection control specialist doing this review may have an unusual skill to notice something out of the ordinary, a pattern or trend in the results. And unusual microbes or patterns of test results may be noticed by the laboratory staff, or patient's nurses and MDs. But there is much more in-depth analysis required to find proof of patterns of infections, and their origin.
First, It must be determined if the patient truly has an infection. A documented prescription of antibiotics is not evidence of infection. Charts must be scrutinized for patient history, exposure to others, diagnostic and invasive procedures, treatments and clinical status. Once it's determined that a patient has an infection, the next question must be answered. Did they acquire it as a result of this admission or a previous one? What about during an outpatient visit? If yes, it's now a healthcare associated infection (HAI). Its source must be found, transmission eliminated and preventative measures established.
The advent of lab information systems (LIS) catapulted infectious disease surveillance forward. Personal computers, database, spreadsheet and statistical software packages allowed manual reports to be entered into systems and truly analyzed as data. Even though the analysis was often long after events occurred, patterns and trends could be seen, reports generated and procedures changed to prevent their reoccurrence. And yet, while information technology revolutionized patient and resource flow throughout health systems, infection control was, and still is, being left behind.
Why is it taking so long to catch up? Good question. To start with, infection control and prevention department staff have an extraordinary scope of responsibilities. Every healthcare organization has an infection control program. In the largest medical centers, there may be a staff of six to eight, including a Ph.D. epidemiologist and or an infectious disease physician. In a smaller hospital, this essential mission may be addressed by one person, investigating the infections of 300 occupied beds. But most often, there are far too few to be proactive in their efforts and sadly, there is important work which goes undone.
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Those who find time to read the literature or attend conferences began to hear about the innovators in infection control informatics at WashingtonUniversity, St. Louis or the University of Utah over 10 years ago. But most didn't know how or wouldn't dare ask their IT department to create a complex database and analysis system. But for about four years now, they are hearing from system developers and vendors. (see table)
They've seen demonstrations of infection surveillance technology, and while some have just been too overwhelmed to investigate the variety of products and services available, hundreds of hospitals have now signed up and are automating surveillance. While the opportunities to become informed are many and the desire to acquire surveillance technology is strong, the financial justification is difficult. Infection prevention and control is not a revenue generator. Without this leg to stand on, highly experienced professionals will not make the request for thousands to hundreds of thousands of dollars for these services.
But this technology is here and it is proving to provide an outstanding return on investment because labor savings brought about by automating surveillance are huge. The efficiency of any infection prevention team can be radically improved. But these systems present tremendous opportunities to improve the effectiveness and substantially impact patient outcomes.
Surveillance systems offer advantages which expedite provision of actionable information about infected patients to their healthcare workers. These products offer alerting mechanisms which will notify users when pre-determined criteria are met. e.g. A patient in an ICU who now has a highly resistant bacteria in their cultures; a patient seen in the emergency department two days ago has a highly contagious virus and is now transferred to a rehabilitation unit; there is a spike in the number of surgical site infections on the cardiac floor.
These user or system defined notifications can be collected and communicated quickly once verified in the lab information system. This allows infection control staff to take action immediately if needed. Disease transmission can be stopped in its tracks, shaving days, weeks or even months off of the traditional processes. Because complex queries can be run ad hoc on huge data bases, powerful information can be used to find and solve problems which otherwise may never have been detected. Reports can be customized to meet a variety of needs from nurse managers to the board directors to state epidemiologists.
Surveillance technology saves money for the organization. Some healthcare workers, physicians and even administrators live in the myth that even though many patients are on fixed fee-for-service payments, an infection that requires a longer stay, generates a higher reimbursement. This is seldom correct. Reimbursement is based on accurate coding. Not all patients with HAIs are coded correctly. Patients with serious HAIs can require days to weeks of additional stay, diagnostic procedures and therapy.
National estimates and history show that an average of 5 percent of inpatients will get an HAI. This adds an average of $11,000 to hospital costs, and can increase length of stay an average of 10 days. In 2002, over $6 billion were spent caring for patients with HAIs. They are a huge source of revenue loss, prevent access for care of others patients and cause of preventable patient suffering and death.
All 50 states, counties and the largest cities require reporting of a long and growing list of communicable and other infections. But as of this writing, 37 states have also passed or are studying legislation to mandate reporting of HAI's. The burden of this required reporting could be eased and improved by implementation of surveillance technology.
The Centers for Disease Control and Prevention have a voluntary surveillance program with several hundred participants. Because of the value of this data for national benchmarking, it will be expanding its services to nationwide. While this program may be accepted by some states to fulfill their mandatory reporting requirements, states may develop and revise their own programs. Infection prevention and control professionals must be able to readily access, analyze and electronically send any demanded variations of this data.
The merging of ADT files with lab and other clinical data also enables the IC staff to go outside and find patterns of infections occurring in affiliated centers: clinics, rehabilitation centers, long-term care and ambulatory surgery centers. Inpatients and outpatients trade places and carry their microbes with them. The ability to monitor all sites and services in the organization benefits everyone.
Seldom touted by those in infection prevention, but of great significance to public health, this technology can make a real impact on curbing the development of microbe resistance to antimicrobial drugs. Rapid generation of reports or alerts which indicate the presence of a highly resistant microbe or an overall increase in resistance, can impact physician's use and choice of antibiotics. Trending in resistance, antimicrobial costs and over-utilization can be tracked by specific patient populations and providers.
Why can't your current LIS, CDR, or enterprise system meet this need? The custom programming, analytical speed and agility required to achieve the goal will demand staff resources you may not be able to provide. When asked, give guidance to your infection control manager through the process you use to evaluate new systems.
Have them include your department to determine important answers to the questions you already know to ask:
- What are the equipment and software requirements and where will they reside?
- Who is responsible for maintenance and upgrades?
- What is done to guarantee data security?
- How is data validation conducted?
Allow the IC staff to educate you about their responsibilities and assist them with product evaluations and contract negotiation. Once a vendor is chosen and product decision made, help them with the financial justification and provide them with an experienced and helpful project manager.
Finally, don't expect infection control professionals to speak your language. They may not know a server from a waitress. But it's possible they may tell you they've selected a vertical market ASP solution package and they'd need your sign off on the RFP. Either way, you have the opportunity to go beyond status quo of merely reducing the number of HAI's. You can contribute to what should be the norm — zero tolerance of healthcare acquired infection.
Jill Midgett, MT, SM (ASCP), is director product development, Association for Professionals in Infection Control & Epidemiology, Washington, D.C.
Surveillance technology products currently available for Hospital Infection Control
Setnet Infection Control,
PharmWatch Antibiotic Management
Application Service Provider
Data Mining Surveillance
Application Service Provider
Infection Control Assistant,
Knowledge Expert System