Affinity Health Services, Inc.
Title of Policy: Surveillance of Healthcare-Associated Infections
Location of Policy: Infection Control Manual
Effective Date: December 2007
Prepared by: MES
Revision Dates:
Total pages: 4
Attachments:
Approved by:
MES
Surveillance of Healthcare-Associated Infections
Highlights
Policy Statement
The Infection Control Coordinator will conduct ongoing surveillance for
Healthcare-Associated Infections (HAIs) and epidemiologically
significant infections that have substantial impact on potential resident
outcome and that may require transmission-based precautions and
other preventative interventions.
Purpose of Surveillance
of Infections
Policy Interpretation and Implementation
The Surveillance of Infections
1. The purpose of the surveillance of infections is to identify both
individual cases and trends in the transmission of epidemiologically
significant organisms and Healthcare-Associated Infections, to permit
interventions to try to slow or stop the transmission of such infections.
Criteria
2. The criteria for such infections are based on the current standard
definitions of infections.
Monitoring Residents for
Signs/Symptoms of
Infection
3. Nursing Staff will monitor residents for signs and symptoms that may
suggest infection, according to current criteria and definitions of
infections, and will document and report suspected infections to the
Charge Nurse as soon as possible.
Reporting Suspected
Outbreak
4. If a communicable disease outbreak is suspected, this information
will be communicated to the Charge Nurse immediately.
Identification/Confirmation
of Cultures
5. When infection or colonization with epidemiologically important
organisms is suspected, cultures will be sent to a contracted laboratory
for identification or confirmation. When necessary or appropriate,
cultures will be further screened for sensitivity to antimicrobial
medications to help determine treatment measures.
Determination of Lab
Tests/
Special Precautions/
Treatment Plan
6. The Charge Nurse will notify the Attending Physician and the
Infection Control Coordinator of suspected infections. The Infection
Control Coordinator and the Attending Physician will determine if
laboratory tests are indicated, whether special precautions are
warranted and if the infection is reportable. The Attending
Physician and interdisciplinary team will determine the treatment plan
for the resident.
Data Collection
7. If transmission-based precautions or other preventative measures
are implemented to slow or stop the spread of infection, the Infection
Control Coordinator will collect data to help determine the effectiveness
of such measures.
Reporting
8. When transmission of Healthcare-Associated Infections continues
despite documented efforts to implement infection control and
prevention measures, the appropriate notifications will be done per the
Reportable policies.
Affinity Health Services, Inc.
Infection Control Manual 2007
Page 1 of 4
Surveillance of Healthcare-Associated Infections
Personnel Authorized to
Gather/Interpret Data
Indicators of HealthcareAssociated Infections
Laboratory Reports That
Merit Further Evaluation
Prioritizing Reports
Purpose of Surveillance
System
Collection of Data
Gathering Surveillance Data
1. Only the Infection Control Coordinator or designated infection control
personnel are authorized to gather and interpret surveillance data.
2. The surveillance should include a review of any or all of the following
information to help identify possible indicators of Healthcare-Associated
Infections:
a. Laboratory records;
b. Skin care sheets;
c. Infection control rounds or interviews;
d. Infection surveillance sheets;
e. Temperature logs;
f. Pharmacy records (e.g., residents on antibiotics); and
g. Transfer log/summaries.
3. If laboratory reports are used to identify relevant information, the
following findings merit further evaluation:
a. All positive blood cultures;
b. All positive wound cultures that do not just represent surface
colonization;
c. Urine culture results combined with urinalysis results that suggest
infection, not just colonization;
d. A positive sputum (not just phlegm from the throat) culture;
e. Other cultures with pathogens (i.e., stool culture, eye cultures,
etc.); and
f. All Group A Streptococcus cultures.
4. After removing duplicates and negative reports, prioritize the reports
as follows:
a. All MRSA, VRE, and Group A Streptococcus reports require
immediate attention. Ensure that certain adequate barriers are in
place. If this is a new or unexpected report (except throat cultures)
notify the Administrator, Director of Nursing Services, and Medical
Director;
b. Blood cultures;
c. Wound cultures that do not just reflect colonization;
d. Sputum cultures (not just phlegm) positive for pathogens;
e. Urine cultures combined with urinalysis results that show a urinary
tract infection, not just colonization;
f. Other positive cultures (i.e., eye cultures).
5. In addition to collecting data on the incidence of infections, the
surveillance system is designed to capture certain epidemiologically
important data that may influence how the overall surveillance data is
interpreted; for example, focused surveillance data may be gathered for
residents with a high risk for infection or those with a recent hospital
stay.
6. Collect the following data as appropriate:
a. Identifying information (i.e., resident’s name, age, room number,
and Attending Physician);
b. Diagnoses;
c. Admission date, date of onset of infection (may list onset of
symptoms, if known, or date of positive diagnostic test);
d. Infection site (be as specific as possible, e.g., cutaneous infections
should be listed as “pressure ulcer, left foot,” pneumonia as “right
upper lobe,” etc.);
e. Pathogens;
f. Invasive procedures or risk factors (i.e., surgery, indwelling tubes,
Foley, etc., fractured hip, malnutrition, altered mental status, etc.);
Affinity Health Services, Inc.
Infection Control Manual 2007
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Surveillance of Healthcare-Associated Infections
Determination of
Infection
Healthcare-Associated
Infections Worksheet
Identify Predominant
Organisms
Comparison of Current
Data
to Previous Data
Monthly Infection
Report
for All Nursing Units
Calculating Incidence
Rates
Processing
Surveillance
Data
Formula for
Determining
Percentage of
Residents
Infected
Formula for
Determining
Percentage of
Infections
g. Pertinent remarks (additional relevant information, i.e.,
temperatures, other symptoms of specific infection, white blood cell
count, etc.). Also, record if the resident is admitted to the hospital, or
expires;
h. Preventive measures and comments (interventions and steps
taken that might have decreased risk, or would do so in the future
(i.e., barrier techniques, efforts to prevent immobilization, appropriate
handwashing, resident noncompliance, etc.).
7. Using the current suggested criteria for Healthcare-Associated
Infections, determine if the resident has a Healthcare-Associated
Infection.
8. Organize the data in the Healthcare-Associated Infections
Worksheet. Indicate in the appropriate column the number of infections
that correspond to the pathogenic organism and site of infection.
9. Identify predominant organisms or sites of infection among residents
in the facility or in particular units.
10. Compare prevalence of current infections to previous data to
identify trends and patterns. Use an average infection rate over a
previous time period (for example, 6 months or a year) as the baseline.
Compare subsequent rates to the average rate to identify possible
outbreaks.
11. Using the Monthly Infection Report for All Nursing Units, enter the
number of infected residents and number of infections in appropriate
columns.
Calculating Infection Rates
1. Obtain census data from the business office. The following data may
be used to calculate different incidence rates:
a. Average daily census (total number of residents in the facility
every day added together, then divided by the number of days in the
designated time period);
b. Total number of residents at risk (total number of residents who
were in the facility during the surveillance period. This is tabulated by
starting with the total of residents at day one, and adding every
admission to the facility within the designated time period); or
c. Total resident days (daily census of each day in the designated
time period added together).
2. To determine different incidence rates within the facility, divide each
of the two numerators (number of infected residents and number of
infections) by the denominator (average daily census) and multiply the
results by 100, so that the rates can be expressed as percentages.
a. For example, if fourteen (14) residents have a total of sixteen (16)
infections, the tabulations would look similar to the following.
(Note: Calculations are based on a 133-bed facility with an average
daily census of 126 for a period of thirty (30) days.)
Total number of residents newly infected for the month =14
Average daily census for the month = 126
Percentage of residents infected 14 ÷ 126 x 100% = 11.1%
Total number of new infections for the month = 16
Average daily census for the month = 126
Percentage of infections in the month 16 ÷ 126 x 100% = 12.7%
Affinity Health Services, Inc.
Infection Control Manual 2007
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Surveillance of Healthcare-Associated Infections
Incidence Rate
Calculations
3. Note that incidence rate calculations above are simply different ways
of presenting the same data. By collecting data in various ways for at
least the preliminary period, the facility can identify the most meaningful
approach.
(Note: Incidence rates can be determined for the facility as a whole or
for individual units. Targeted studies using specific infection data may
be performed to identify problem areas.)
Analyzing Surveillance
Data
Review of Surveillance
Data by Infection Control
Team and Committee
OBRA Regulatory
Reference Numbers
Related Documents
Interpreting Surveillance Data
1. Analyze the data to identify trends. Compare the rates to previous
months in the current year and to the same month in previous years, to
identify seasonal trends. Consider how increases or decreases might
relate to recent process changes, events, or activities in the facility (i.e.,
change in handwashing preparations, increased turnover in personnel
or residents, etc.). These, of course, are not necessarily the reason for
the change. However, trends should be monitored. If the infection rates
rise each month over a period of six (6) months, additional advice is
warranted.
2. Surveillance data will be provided to the Infection Control Team and
Committee regularly. The Infection Control Committee will determine
how and to whom important surveillance data will be communicated.
References
483.65(a) Survey Tag Numbers F441
Healthcare-Associated Infections Worksheet; Monthly Infection Report
for Individual Nursing Units; Surveillance of Nosocomial Infections –
CDC Definitions of Nosocomial Infections
Affinity Health Services, Inc.
Infection Control Manual 2007
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Surveillance of Healthcare-Associated Infections