Surveillance Essentials - Peel Region€¦ · “If surveillance data are not used to effect changes to IPAC practices, then the surveillance system is not working.” (PIDAC, Best

Surveillance Essentials

October 1, 2019

Madeleine Ashcroft

PublicHealthOntario.ca

Acknowledgements

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Best Practices for Surveillance of Health Care-Associated Infections in Patient and Resident Population was developed by the Provincial Infectious Diseases Advisory Committee (PIDAC)


Objectives

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• Define surveillance and the importance of data collection, collation, and analysis

• Consider the population at risk and determine priorities

• Establish case definitions

• Review data collection strategies, analysis, and evaluation

• Apply your knowledge in case scenarios


What is Surveillance?

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• “Surveillance is the systematic ongoing collection, collation and analysis of data with timely dissemination of information to those who require it in order to take action”

• Public Health Ontario, Provincial Infectious Diseases Advisory Committee. Best Practices for Surveillance of Health Care Associated Infection in Patient and Resident Populations, July 2014, p. 9 Available from: http://www.publichealthontario.ca/en/eRepository/Surveillance_3-3_ENGLISH_2011-10-28%20FINAL.pdf

http://www.publichealthontario.ca/en/eRepository/Surveillance_3-3_ENGLISH_2011-10-28%20FINAL.pdf


Surveillance Should

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• Go beyond just collecting information or numbers

• Be an organized and ongoing component of IPAC program

• Include investigation of sentinel events and unusual or relevant pathogens

• Be an action plan for improvement


Surveillance Should

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• Look at outcomes• Collect data on individual cases• Use standard case definitions• Determine Healthcare Associated Infections (HAIs)

• Look at processes• Ongoing audits of practice• Verifying that procedures and/or standards of

practice are being followed


Why Have a Surveillance System?

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• Healthcare Associated Infections (HAIs) are an important and growing concern in Canada and a Public Health concern

• Increasing prevalence of AROs and a vulnerable immuno-compromised population in healthcare facilities

• Use of a surveillance system → reduction in infections

• Also monitors the impact of IPAC measures and programs


Components of an Active Surveillance Program

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• Planning

• Data Collection

• Data Analysis

• Interpretation of Data

• Communication of Results

• Evaluation


Planning: Assess the Population

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• Types of patients/residents/clients:

• Catchment area

• Socio-demographic profile

• Key medical interventions or procedures

• E.g., indwelling urinary catheters

• Most common infections

• Impact

• Preventability

• Types of infections for which they are most at risk

• Any health concerns emerging from the community

• E.g., community – associated MRSA


Planning: Select Outcome or Process

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• Outcome Surveillance

• Monitors definable events or outcome

• E.g., Influenza cases/rates

• Results lead to action plan which leads to quality improvement

• Process Surveillance

• Verifies that procedures and or standards of practice are followed

• E.g., hand hygiene compliance rates

• How are processes being applied?

Process surveillance is important and proactive in preventing infections - Puts the “P” in IPAC!


Planning: Outcome Surveillance

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• Facility-wide surveillance is NOT recommended

• Based on the frequency, impacts, and preventability of the infection

• Preventable infections are the focus of surveillance

• Surveillance should be connected to an action or improvement

• Outcomes selected for surveillance should be re-evaluated at least annually


Planning: Outcome Surveillance

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• Recommended for non-acute settings:

• Acute respiratory infections (ARIs) - e.g., influenza

• Gastroenteritis/Gastrointestinal infections:

• E.g., Clostridium difficile infection (CDI), Norovirus

• Skin and soft tissue infections

• Urinary tract infections (UTIs)

• Antibiotic Resistant Organisms (AROs – e.g., MRSA, VRE, ESBL)

• Consider:

• Group A Strep

• Hepatitis in hemodialysis residents

Surveillance Planning


PIDAC - Outcome Indicators

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http://www.publichealthontario.ca/en/eRepository/BP_IPAC_Ontario_HCSettings_2012.pdf



Planning: Case Definition

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• Apples versus oranges

• Must use established case definitions over time to have usable comparative data!

• Must ensure that all who do surveillance use definition consistently

• E.g., HAI- occurs more than 48-72 hours post admission and no evidence present or incubating at admission


Planning: Case Definition in LTC

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• Use the revised McGeer et al. definitions of infections for surveillance in long-term care facilities by Stone et al (2012)

• Appendix D of the PIDAC Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations page 97-103

• http://www.publichealthontario.ca/en/eRepository/Surveillance_3-3_ENGLISH_2011-10-28%20FINAL.pdf


PublicHealthOntario.ca 17

E.g., Respiratory Tract Infection:

• A resident or staff member on any unit of the home with illness onset from (date) who is experiencing any two of the following symptoms:

• Cough

• Fever

• Headache

• Chills

• Lethargy or

• Muscle ache

The definition can be modified if necessary to ensure that the majority of cases are captured by the definition

Planning: Application of Case Definition


Planning: Process Surveillance

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• To measure resident processes: things done to or for a resident within the health care system

• E.g., audits

• See the PIDAC Best Practices for Infection Prevention and Control Programs in Ontario in All Health Care Settings


• To measure resident processes: things done to or for a resident within the health care system

• E.g., audits

• See the PIDAC Best Practices for Infection Prevention and Control Programs in Ontario in All Health Care Settings

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Staff FacilityCompliance with:

• Screening for TB

• Hand hygiene*

• Routine Practices – use of PPE

Immunization Rates:

• Influenza

• Injury surveillance

Compliance with:

• Reprocessing practices

• Environmental cleaning

• Construction/renovation practices

• Antimicrobial stewardship

• Urinary catheter use

• Hand hygiene*


PIDAC - Process Indicators

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PIDAC Process Indicators (continued)

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Audit Tools for Process Surveillance: IPAC Canada

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https://ipac-canada.org/tools-intro.php

https://ipac-canada.org/tools-intro.php


Data Collection: Sources

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• Method must be consistent and simple to maintain

• Total chart review for all residents is not recommended

• Choose the best method for the data you are collecting:

• Active surveillance• ICP seeks data on regular basis using data sources

• ICP uses case definitions

• Most sensitive

• Passive surveillance• Sentinel reporting by staff

• Least sensitive

Image source: PIDAC Surveillance Best Practices, page 43


Data Collection: Sources

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• Micro and lab reports

• Patient/resident/client records - e.g., progress notes, care plan, profile

• Unit or floor rounds – Extremely valuable!

• Surveillance sheets/reports completed by staff

• Line listings

• Sentinel reports

• Electronic records

• Antibiotic utilization records


Collecting Data: Who?

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• Collect data on those who actually acquire an infection (numerator) and

• Group at risk for acquiring HAIs (denominator) –expressed as total number of resident days within the time frame

• E.g. for urinary tract infections:

Numerator = those with UTIs

Denominator = total number of days that all residents were at risk of developing a UTI


Collecting Data: Additional Information

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Surveillance rates are adjusted for:

• Length of stay – i.e., resident days

• Type of procedure – i.e., eye versus bowel surgery

• Exposure to medical devices – i.e., urinary catheters


Data Collection: Implement the System

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• Use the data sources

• Develop a line list or use a form

• Chart review for individual patient/resident/client

• Meets case definition?

• Reported as HAI

• May use a software system or data base system


Data Collection: Ensuring Complete Data

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• Check to ensure that data sources are complete

• Audits of surveillance system

• Assess timeliness of system

• Regular feedback of data encourages reporting


Data Analysis: Elements

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Must have access to 3 data elements:

• The number of cases of the infection

• The number of persons at risk

• The time period involved

Must be able to create rates - not just numbers!


Data Analysis: Rates

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• Data needs to be adjusted for risk factors and to do this we calculate a rate

• Rate

• Numerator

• Denominator

• Includes time measures

• X (numerator) X K (constant)

Y (denominator)

• All members of the numerator must also be members of the denominator


Data Analysis: Incidence Rate

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• Measurement of new cases of disease within a population over a given period of time (patient/resident days is often denominator)

• # of new cases x constant population at risk for event (1000)

E.g., # of ARI cases during first quarter x 1000

number of resident days for the first quarter

4 x 1000 = 3.1 ARI cases per 1000 resident days

1276


Example of Incidence rates

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Data Analysis: Device Associated Rates

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Device associated infection rates =

X (number of infections in residents exposed to device x k

Y (total number of days that all residents were exposed to device)

7 UTIs in residents with indwelling catheters x 1000

1790 resident catheter days

= 3.9 UTIs per 1,000 resident catheter days


Data Analysis: Prevalence Rates

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• Point prevalence

• All existing and new HAIs on a single day

• Period prevalence

• All existing and new HAIs over a specified time period

# of existing cases and new HAIs x constant

population at risk


Interpretation

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• What does all this data mean?• Are the rates accurate? – computer helps!

• Does the data make sense?

• Are there major deviations from previous, baseline, or other comparator rates?

• Am I answering the main question?

• If major deviation, was there a change in:• Actual practice?

• Lab methods?

• Surveillance?

• Case definition?


Interpretation: Benchmarking

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• Recognized standards or benchmarks (NNIS/NHSN, CNISP, Patient Safety provincial averages)

• Rates from previous surveillance periods

• Internal benchmarks or peer facilities

• All rely on consistently using the same:

• Case definition

• Data collection methods including sources over time


Interpretation

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Internal External


Investigation of Increased HAI Rates

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• Image sources: PIDAC Routine Practices and Additional Precautions , November 2012, page 1


Communication

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“If surveillance data are not used to effect changes to IPAC practices, then the surveillance system is not working.” (PIDAC, Best Practices for Surveillance, 2014, page 72)

• Health care setting level:• All departments

• Infection control team and Committee

• Specific area of resident care:• Targeted written reports directed to those who affect care

• Special alerts and outbreaks• Key information

. . . to those that can impact change!


Communication: Tips

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• Know your audience

• Focus on the main message and make it clear and easy to follow

• Present your information through good report design

• Provide recommendations


Communication: Making the data talk

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• Graphics

• Line graphs with rates over time

• Bar graphs comparing units/home areas

• Place benchmark data on the graph for comparison

• Can also be used for incidence rates

• Easy to interpret

• Include title and subtitle

• Label axes, timeframe, denominator, and legend


Different types of graphs

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Bar Graph

Pie Graph

Frequency Polygon


Evaluation

• Process evaluation• Audit the process of surveillance• How efficient and effective?• How appropriate are the methods?

• Outcome evaluation• Did the system detect outbreaks or clusters?• Were improvements/changes made?• Did we assess the impact of changes?• Did we reduce the risk of infection and overall rates?

• Ongoing evaluation• Should we change our objectives?• Are there new standards, best practices, organisms, or syndromes?

Evaluation


Evaluation: Fundamentals

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1. Will the information I collect through surveillance be used to make improvements in resident care?

2. Can I collect the data I need with the time and resources on hand?

If yes to 1 and 2 ,then move on.

If no to 1 or 2—stop!

Evaluation


LTC Example

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• 120 bed long term care home

• Has 6-8 residents with indwelling urinary catheters per month

• Uses antibiotics to treat various infections

• Implementation of hand hygiene program in progress

• Recent history of Norovirus and respiratory outbreaks

Where would you start?

What would you focus on?


A Suggested Approach

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• May want to track not only CAUTI but also indwelling catheter usage rates (per resident days)

• Respiratory and Gastrointestinal syndromic surveillance

• Hand hygiene compliance

• Other best practice recommended surveillance - e.g., AROs: MRSA, VRE, Clostridium difficile

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Test Your Knowledge!


What is the main purpose of surveillance in LTC?

A. Tracking all infections in residents for a total picture

B. Tracking and reporting infections quarterly to infection control committee to detect outbreaks

C. Collecting, collating, analyzing, and reporting infection data to those who require it to make changes


What is the main purpose of surveillance in LTC?

A. Tracking all infections in residents for a total picture

B. Tracking and reporting infections quarterly to infection control committee to detect outbreaks

C. Collecting, collating, analyzing, and reporting infection data to those who require it to make changes


What are the first steps in reviewing or setting up a surveillance system in LTC?

A. Collect data, develop reports, and send to infection control committee

B. Check with a local acute care facility to see what data they collect and develop system to mirror theirs

C. Assess the population at risk, select outcomes, and determine accepted case definitions


What are the first steps in reviewing or setting up a surveillance system in LTC?

A. Collect data, develop reports, and send to infection control committee

B. Check with a local acute care facility to see what data they collect and develop system to mirror theirs

C. Assess the population at risk, select outcomes, and determine accepted case definitions


Which are examples of surveillance outcomeindicators in LTC?

A. Facility-acquired respiratory infections, skin and soft tissue infections, and staff TB skin test conversions

B. TB skin test conversion rates, surgical site infections, and healthcare-acquired AROs (MRSA and VRE)

C. Soft tissue infections, healthcare-acquired C. difficileinfections, and hand hygiene compliance rates


Which are examples of surveillance outcomeindicators in LTC?

A. Facility-acquired respiratory infections, skin and soft tissue infections, and staff TB skin test conversions

B. TB skin test conversion rates, surgical site infections, and healthcare-acquired AROs (MRSA and VRE)

C. Soft tissue infections, healthcare-acquired C. difficileinfections, and hand hygiene compliance rates


What are best data sources for LTC surveillance?

A. Monthly nursing unit reports, lab reports, and resident chart review

B. Unit ward rounds on regular basis, microbiology reports, and resident chart review

C. Resident reports of their infections, unit rounds on a monthly basis, and micro reports.


What are best data sources for LTC surveillance?

A. Monthly nursing unit reports, lab reports, and resident chart review

B. Unit ward rounds on regular basis, microbiology reports, and resident chart review

C. Resident reports of their infections, unit rounds on a monthly basis, and micro reports.


What type of surveillance is best to do?

A. Total house surveillance of all infections found

B. Surveillance collected through monthly reports from units

C. Surveillance targeted towards infections that are expected in the population at risk


What type of surveillance is best to do?

A. Total house surveillance of all infections found

B. Surveillance collected through monthly reports from units

C. Surveillance targeted towards infections that are expected in the population at risk


What do increases in infection rates most likely mean?

A. There is a definite problem in the facility

B. Hand hygiene and compliance with IPAC is lower than normal

C. Further investigation is required to determine if there is a problem and what the causes may be


What do increases in infection rates most likely mean?

A. There is a definite problem in the facility

B. Hand hygiene and compliance with IPAC is lower than normal

C. Further investigation is required to determine if there is a problem and what the causes may be


Case Scenario

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• You are the ICP in a 150 bed LTC home (5 separate units of 30 beds)

• For the months of November, December, and January, there has been full occupancy on all units

• One resident, Mr. A., has MRSA• He was MRSA positive on admission on year ago and remains

positive

• Swabs are no longer being obtained based on PIDAC document

• For the last couple of months his direct care activities have increased


Case ScenarioYou report your incidence rate monthly:Mr. A. is on a 30 bed unit. What is Mr. A’s unit rate for MRSA for November?

A. 0

B. 3.3

C. 30

D. 0.3


Case ScenarioYou report your incidence rate monthly:Mr. A. is on a 30 bed unit. What is Mr. A’s unit rate for MRSA for November?

A. 0

B. 3.3

C. 30

D. 0.3


Summary

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• Surveillance consists of planning, data collection, data analysis, interpretation of data, communication, and evaluation

• Select outcome and process surveillance that have improvement attached

• Be consistent!

• Communicate results to those that influence the improvement


References

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PIDAC Best Practices:

• Public Health Ontario, Provincial Infectious Diseases Advisory Committee. Best Practices for Infection Prevention and Control Programs in Ontario In All Health Care Settings, 3rd edition, May 2012. Available from: http://www.publichealthontario.ca/en/eRepository/BP_IPAC_Ontario_HCSettings_2012.pdf

• Public Health Ontario, Provincial Infectious Diseases Advisory Committee. Best Practices for Surveillance of Health Care Associated Infection in Patient and Resident Populations, July 2014. Available from: http://www.publichealthontario.ca/en/eRepository/Surveillance_3-3_ENGLISH_2011-10-28%20FINAL.pdf

• Public Health Ontario, Provincial Infectious Diseases Advisory Committee. Routine Practices and Additional Precautions In All Health Care Settings, 3rd edition, November 2012. Available from: http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf



http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf


More Useful Resources

• Canadian Patient Safety Institute: www.patientsafetyinstitute.ca/

• Patient Safety Indicator Results at Health Quality Ontario: http://www.health.gov.on.ca/en/public/programs/patient_safety/

• Essential Resources for Effective Infection Prevention and Control Programs: A Matter of Patient Safety - A Discussion Paper (2010): http://www.phac-aspc.gc.ca/nois-sinp/guide/ps-sp/partII-eng.php#b532

http://www.patientsafetyinstitute.ca/

http://www.health.gov.on.ca/en/public/programs/patient_safety/

http://www.phac-aspc.gc.ca/nois-sinp/guide/ps-sp/partII-eng.php#b532

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Documents

Surveillance Essentials - Peel Region€¦ · “If surveillance data are not used to effect changes to IPAC practices, then the surveillance system is not working.” (PIDAC, Best