Tool for Assessing a Nosocomail Infection Surveiallnce ...



Tool for Assessing a Surveillance Program

In the Ambulatory Surgery Care (ASC) Setting*

|Recommended Practices |

|Recommended Practices |Examples of Compliance |Facility Evidence of Compliance |

|I. Risk Assessment: The surveillance system should be based on an |1. The ASC conducts an annual risk assessment and documents findings. | |

|evaluation of the populations served: |Some findings include: | |

|Types of patients/clients served |ASC is a privately-owned facility, not associated with a local hospital, | |

|Most common diagnoses |located in a small town (population 10,0000) | |

|Types of surgical or other invasive procedures performed |ASC serves both adult and pediatric patients | |

|Risks of infection for procedures and treatments performed |The most common procedures performed are: lens and cataract procedures, | |

|Which patients are at risk for infection |laparoscopic cholecystectomy, laminectomy, inguinal and femoral hernia | |

|Diseases in the community and region |repair, and tonsillectomy and/or adenoidectomy | |

| |Many procedures involve the use of scopes | |

| |MRSA occurs often in the community and area healthcare facilities | |

| |. | |

|II. Selecting the indicators (events) to monitor: |ASC conducts surveillance for surgical site infections (SSI) related to | |

|Outcome or process indicators selected should have an important impact on|lens and cataract procedures, laminectomy, inguinal and femoral hernia | |

|the population served. |repair, and tonsillectomy and/or adenoidectomy | |

|Selection of indicators to be monitored should occur in conjunction with |ASC refers to CMS, State, and accrediting agency requirements when | |

|the population assessment. |selecting indicators (events) to monitor | |

|Review regulatory or accrediting agency requirements when selecting |ASC monitors compliance with hand hygiene, safe injection/medication | |

|outcome or process indicators for surveillance. |practices and scope processing protocols (including cleaning, | |

| |disinfections, storage) | |

| |ASC monitors all culture reports for MRSA | |

| |ASC conducts surveillance for diseases reportable to the State Health | |

| |Department | |

|III. Using surveillance definitions: All data elements should be clearly |In its Surveillance Plan, the ASC delineates the data it collects to | |

|defined. |identify SSIs related to the procedures monitored. The Surveillance | |

| |Program uses CDC National Healthcare Safety Network (NHSN) methodology | |

| |and surveillance definitions as criteria for categorizing an infection.1 | |

|IV. Collecting surveillance data: |The Infection Preventionist (IP) has attended an infection prevention and| |

|Data collection process should be managed by knowledgeable professionals.|control training course that included instructions on how to conduct | |

|Data should be collected consistently. |surveillance. | |

|Appropriate information sources should be available. |Surveillance data has been collected by a trained IP using the same | |

|Appropriate tools should be used to collect data. |methodology for over 12 months. | |

|Appropriate post-discharge surveillance should be used. |A standardized data collection form is used for each surveillance | |

| |indicator. | |

| |Laboratory reports, physician reports, patient charts, and electronic | |

| |medical records are used when collecting surveillance data. | |

| |The IP uses a personal computer to collect, store and manage data. | |

| |ASC surgeons are required to complete a post discharge SSI surveillance | |

| |program form and return to IC department | |

| |The same person collects surveillance data using a standardized data | |

| |collection form. If that person is out of work for a prolonged period | |

| |(such as a 2-week vacation), a mechanism is developed to obtain accurate | |

| |surveillance data during that period. | |

|V. Calculating and analyzing data: |Surveillance program uses rates (not raw numbers) to measure and compare | |

|Rates should be used when numerically measuring an outcome or process. |SSIs and other events monitored over time. | |

|Appropriate calculations should be used and reported. |IP uses appropriate methodology, numerators, and denominators for | |

|Consistent methodology should be used over time. |calculating rates.1,2 | |

|All aspects of surveillance must be equivalent in order to compare rates |To ensure consistent surveillance data, the IP uses standardized data | |

|over time within an institution or between institutions. |collection forms and CDC NHSN definitions and methodology.1 | |

|VI. Applying risk stratification methodology: A risk stratification |CDC NHSN risk stratification is used for SSI surveillance1 (i.e., a | |

|method should be used. |record on every patient undergoing a monitored NHSN operative procedure | |

|For some rates, risk stratification is not possible. |is generated that includes the data required in the NHSN Manual) | |

|If rates are stratified, assure that subpopulation sizes are large enough| | |

|to be statistically meaningful | | |

|VII. Reporting and using surveillance information: |A written Annual Surveillance Plan describes the persons and committees | |

|There should be a plan for the distribution of surveillance information. |to whom surveillance reports are distributed. | |

|Surveillance results should be reported to those who are most able to |Surveillance findings are reported to the Quality Assurance/Performance | |

|impact and improve patient care. |Improvement Committee (QAPI) | |

|Reporting should be done on a systematic, ongoing basis. |Reports on SSIs and compliance with safe injection and hand hygiene | |

| |protocols are distributed quarterly to the Medical Director and QAPI. | |

|Essential Elements |

|Essential Elements |Examples of Compliance |Facility Evidence of Compliance |

|A written plan should serve as the foundation of the surveillance |The ASC has a surveillance plan that is based on the populations(s) | |

|program. |served and services provided. The plan includes: | |

| |a brief description of the facility | |

| |a description of the types of services provided and the population (s) | |

| |served | |

| |the objectives of the infection surveillance program | |

| |a description of the surveillance indicators used | |

| |the methodology for data collection | |

| |(e.g., total or targeted; sources of information; use of a standardized | |

| |data collection form) | |

| |the methodology for calculating rates | |

| |a description of the surveillance definitions used | |

| |the types of surveillance reports, and how often and to whom they are | |

| |distributed | |

| |the process for evaluating the effectiveness of the program | |

|Surveillance definitions and rate calculations are applied consistently |CDC NHSN definitions are routinely used.1 | |

|over time. |IP consistently uses NHSN methodology (including numerators and | |

| |denominators specified by the CDC) for calculating SSIs.1 | |

|Personnel resources need to be appropriate for the type of surveillance |The IP is a healthcare professional who has taken a training course | |

|being performed. |provided by APIC. | |

| |The IP understands epidemiologic principles and surveillance techniques. | |

|Other essential resources, such as computer support, information and |The IP has a personal computer linked to the ASC’s computer system and | |

|technology services, clerical services, and administrative understanding |the Internet. | |

|and support are available. |The IP has access to clerical help. | |

| |The Medical Director ensures that the IP has the necessary resources to | |

| |manage the program in accordance with CMS, state and accrediting agency | |

| |requirements. | |

|The surveillance program (including surveillance |The ASC’s Annual QAPI Report outlines the findings of the annual | |

|processes and data), as part of the overall infection prevention and |evaluation of the IC Surveillance Program including the indicators | |

|control program, should be evaluated at least annually. Evaluation |measured and results of performance improvement activities related to | |

|methods may include |infection prevention. | |

|qualitative assessments, but should also be based on | | |

|quantitative changes (e.g., improvements or decline in rates). | | |

Recommended practices and essential elements based on: Lee TB et al. Recommended Practices for Surveillance: Association for Professionals in Infection Control and Epidemiology. Am J Infect Control 2007;35:427-40 (available on APIC website)

1. CDC National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocols available at:

2. Lee T et al. Recommended Practices for Surveillance: APIC. Am J Infect Control 2007;35:427-40 (available on APIC website)

Tool adapted from “Tool for Assessing a Surveillance Program” in Arias K. Surveillance Programs in Healthcare Settings. 2nd ed. Association for Professionals in Infection Control and Epidemiology, Inc: Washington, DC. 2009

Reviewed August 2017

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