Carole Yeung, RN CIC
Nothing to disclose
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Surveillance (in general)
HAI Surveillance
Practical Application
◦ CAUTI Reduction
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Discuss methods for identifying potential
infections using OASIS and applying the
APIC-HICPAC Surveillance Definitions for HHC
and Home Hospice Infections
Describe the use of surveillance to improve
outcome and process measures
Analyze and report findings of the
surveillance data including the development
of action plans
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The hospice must maintain and document an
effective infection control program that
protects patients, families and hospice
personnel by preventing and controlling
infections and communicable diseases
A plan for the appropriate actions that are
expected to result in improvement and
disease prevention
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Current:
◦ No requirement for agency wide program
◦ Must comply with accepted professional standards
& principles that include infection prevention
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Proposed:
◦ Maintain and document a program to prevent and
control infections & communicable disease
◦ Follow accepted standards, including standard
precautions, and educate staff, patients, and
caregivers about proper infection control
procedures
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Surveillance is defined as “the ongoing,
systematic collection, analysis, interpretation
and evaluation of health data closely
integrated with the timely dissemination of
this data to those who need it”.
(Centers for Disease Control and Prevention. CDC surveillance update. Atlanta: Centers for Disease Control
and Prevention, 1988)
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Essential component of an infection prevention &
control program to reduce frequency of adverse
events
Comprehensive method of measuring outcomes
and other processes of care
Systematic methods of collecting, consolidating
and analyzing data concerning distribution &
determinants of a given disease or event
Dissemination of information to those who can
improve outcomes
Outbreak investigation/Performance
Improvement
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No “single” or right method
Based on population served , services provided, &
regulatory or other requirements (Infection
Prevention Risk Assessment)
Requires direct involvement of organization
leaders
Team work and collaboration across the
healthcare spectrum are important in the
development of surveillance plans
Designed in accordance with current
recommended practices and defined elements
Incorporate into Safety & PI Programs
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Written plan serves as the foundation and
should outline important objectives and
elements:
◦ HAI
◦ Non HAI (community)
◦ Non infectious disease events
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Multidisciplinary team
Identify areas of risk and potential impact
on patients, staff, and agency.
Identify risks based on:
◦ Geographic location, community, and population
served
◦ Care, treatment, or services provided
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Evaluate each potential risk in each of the
three categories of probability, impact, and
current systems.
http://www.apicdfw.org/seminar/2008/lee1.pdf Terrie Lee adapted for BHHHN
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Measure outcomes and processes
Monitor a variety of outcomes/processes
Monitor high-risk/high-volume events
Cost/negative impact
Mandates to monitor specific indicators
Determine time period for observation
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CLABSI (Central line associated blood stream infections)
CAUTI (Catheter associated urinary tract infections)
Skin and soft tissue infections
Flu vaccination rates (patients and hcw)
Sharp injuries in HCW
Include community (if applicable)
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Adherence to published standards/best practices
(hand hygiene, infectious disease precautions)
Training and competence of care provided by
family/care givers
Evaluation of specific infection prevention and
control measures (home care bag checks)
Best practices for invasive device infection
prevention
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Outcome:
◦ Catheter Associated Urinary Tract Infection
Reduction by 10%
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Process:
◦ Assure best practices are being followed for care of
a patient with an indwelling catheter
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Goals (broad statements)
Objectives (specific and measurable)
Strategies (steps to take to achieve goals)
Evaluation (how you will measure your
achievement of objectives)
Progress (current measure and next steps)
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Standard definitions to ensure precise
surveillance (preferably published)
Definitions should be consistently used in the
collection, analysis, and reporting of
surveillance data
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When to collect data?
◦ Concurrent
◦ Retrospective
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Who will collect the data?
Where to find data?
How to collect data?
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Unique to the organization
Specific to surveillance plan
Learn from colleagues, reports in the
literature
Collect data from a variety of sources
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Clinicians
OASIS Data
Medical Records (paper, electronic)
Lab reports
Direct Observation
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Data Collection Form
◦ Identify data elements to be collected
◦ Limit data collection to elements that are needed to
identify a case or determine the case criteria are
met for condition or event being studied
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Data must be analyzed, interpreted, and
reported
Expressed in numerical measurement of the
outcome/process observed
Essential that appropriate calculations be
performed and reported with a consistency of
methodology over time for interpretation of
each surveillance component
Data can be non useful if numerator too small
or denominator of inappropriate size
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Rates accurately calculated?
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Major changes from previous data
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Substantially high rates
◦ May signify a problem
◦ Investigate risk factors/processes
◦ No obvious observation
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Design a report
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Federal, state, and local authorities
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Referring or receiving facilities
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Systemic ongoing process
◦ Tables, graphs, charts, and summary graph
◦ Disseminate to managers and healthcare
providers who can use the findings to improve
performance
◦ Healthcare workers
◦ Supervisors/Managers
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Goals:
◦ Enhance safety and quality of patient care
◦ Reductions in:
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Morbidity and mortality
Emergent care
Acute care hospitalizations
Cost
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Purpose:
◦ Assess the safety and quality of patient care by
establishing a baseline and monitoring trends
◦ Use findings to improve care to prevent infections
and other complications
◦ Detect & investigate clusters or outbreaks
(including community)
◦ Assess effectiveness of prevention & control
measures
◦ Ensure regulatory compliance
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Do not routinely include identification of
community-acquired infections
Report infections to other facilities
May be useful to:
◦ Know patients with MDRO’s in the agency and
notify patient infectious status to another
agency/facility if patient is transferred
◦ Assure appropriate precautions
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Describing an infection to the agency does
not mean that they caused it. The following
can increase the risk of infection:
◦ Certain conditions or therapies place pts at
increased risk
◦ Other elements not directly associated with a
persons healthcare status can increase the risk
◦ Environmental factors
◦ Agent factor
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Not intended to be used to make clinical
decisions or to determine treatment
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Consultation with hospital IP may be
beneficial
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APIC-HICPAC Surveillance Definitions for
Home Health Care & Home Hospice
Infections, 2008
Surveillance Form
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Clinicians reporting
Case Conferences
Local hospitals
Networking with local IP’s
OASIS data
• Designated person to review the evidence to
determine if definition for HAI is met
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M2300. Since last time OASIS data collected
has the patient utilized the Emergency
Department:
0 No
1 Yes, use hospital ED without hospital admit
2 Yes, use hospital ED with hospital admit
UK
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M2310 Reason for Emergent Care
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Time Point M2300 & M2310:
◦ Transfer to inpatient facility, with or without agency
discharge
◦ Discharge from agency
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M2430 Reason for Hospitalization
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Time Point:
◦ Transfer to inpatient facility, with or without agency
discharge
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M2310 and M2430
 3 – Respiratory Infection
13 – UTI
14 – IV catheter-related infection or
complication
15 – Wound infection/deterioration
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M1600: has this patient been treated for a
UTI in last 14 days
0 - No
1 - Yes
NA - Patient on prophylactic antibiotics
UK – Unknown
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Time Points:
◦ SOC/ROC
◦ DC from the agency – not to inpatient facility
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Internal:
◦ agency historical data
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External:
◦ Must use same case findings
◦ Must use same case definitions
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IPRA – CAUTI
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2009 rate: 0.9 CAUTI/1,000 catheter days
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Goal: Reduce CAUTI in patients with indwelling catheters
Objective: Reduce CAUTI by 20% next 2 years. (Decrease
antibiotic use. Decrease MDRO acquisitions)
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Improvement strategies:
◦ Review the literature – best practices
◦ Update procedures as necessary
◦ Monitor patients with indwelling catheter during supervisor
visits including hand hygiene
◦ Education – all disciplines
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Evaluation/Progress: Quarterly report to
Administration Team and healthcare workers
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Must meet one of the following criteria and had an indwelling catheter
within the last 7 days:
1. Two of the following signs/symptoms:
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Fever or chills
Flank pain, suprapubic pain, tenderness, frequency, urgency
Worsening mental/functional status
Changes in urine character
AND urinalysis or culture not done
2. One of the following two signs or symptoms:
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Fever or chills
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Flank pain, suprapubic pain, tenderness, frequency, urgency
AND
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Bacteria (positive culture or nitrite)and pyuria (>10 wbc/hpf or leukocytes) on urinalysis
(APIC-HICPAC Surveillance Definitions for Home Health Care and Home Hospice Infections, 2008)
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Potential for subjectivity:
48hrs vs 72 hrs after admission to HC
Changes in urine character?
What constitutes a potential pathogen?
Colony count?
Why is worsening of mental or functional status
not included in criteria 2?
◦ Why 7 days after catheter discontinued?
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Need for more “concrete” criteria if HHC
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Clinicians reporting
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Case Conferences
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OASIS data M2310 and M2430
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13 – UTI
OASIS data M1600
(treatment of a UTI in the last 14 days)
Source: BHHHN - LR
43
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Indwelling urinary catheter days vs patient
days (do not include suprapubic)
◦ Clinicians reporting
◦ Computer profiles
 Clinicians document
 Develop a report (may need IT help)
6 CAUTI
2,132 Catheter Days
X 1,000
= 2.8 CAUTI/1,000 catheter days
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Sterile technique for insertion
Consider using smallest bore catheter as
possible (14–16fr with a 5cc balloon)
Discourage irrigation
Urinary Catheter Maintenance
Patient/caregiver education
S/S infection
Specimen collection/transportation
Catheter removal
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Develop check sheet
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Assess care when perform home visits:
◦ Skilled nurses
◦ Supervisory Visits
◦ AIDES
Compliant
Catheter
connected to
closed drainage
system
Urinary catheter is
secure to prevent
movement
Drainage bag
below level of the
bladder
Family has
education sheet
Non Compliant
N/A
1
Hand
hygiene
before
patient
contact or
putting on
gloves
Hand
hygiene after
patient
contact or
removing
gloves
Hand
hygiene
before
reaching into
home care
bag
2
3
4
5
6
7
Total
%
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Formal – Education days
◦ SN
◦ Therapy and AIDES
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Informal – Case conferences
Best Practices
1.2
Supervisor check list
1
0.8
Education
0.6
0.4
0.2
0
Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov
1.2
1
Total 58%
0.9
0.8
0.57
0.6
0.38
0.4
↓36%
↓33%
0.2
0
2009
2010
2011
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CAUTI rate for 2011 is 0.38/1,000 indwelling
catheter days. A reduction of 58% compared to 2009.
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Procedure updated. Removed standing orders for
irrigating a catheter
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Developed a UTI Prevention CBL for SN and for
Therapy and Aides
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Patient care giver education sheet
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Care of patient with indwelling catheter resulted in >
90% compliance
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Education completed by 98% (141/144) clinicians
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Reported infections do not meet the criteria
but being treated. Over culturing that may
lead to antibiotic resistance
Specimen collected inappropriately – clinical
UTI but culture contaminated
Most patients with catheters have bacteria if
left in >30 days
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APIC: Guide to Elimination of CAUTI, 2008
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HICPAC/CDC: Guideline for Prevention of Catheter Associated
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Best Practice for Indwelling Catheter in the Home Care
Setting. HHN vol.22, no12, Dec 2004
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Catheter Management in a Home Care Setting.
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The Quest for Best Practice in Caring for the HC Patient with
an Indwelling Urinary Catheter: The New Jersey Experience.
Urinary Tract Infections, 2009
Caring, April 2009
HHN vol. 25, No 2, Feb. 2008
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Rhinehart E., & McGoldrick ,M..M. (2006). Infection Control in
Home Care and Hospice. Sudbury MA.Jones and Bartlett.
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Good surveillance does not necessarily ensure
the making of right decisions, but it reduces
the chances of wrong ones”
Alexander Langmuir
Questions?
Carole.Yeung@baptist-health.org