Recommended practices for
               surveillance: Association for
               Professionals in Infection Control
               and Epidemiology (APIC), Inc.
               Terrie B. Lee, RN, MS, MPH, CIC, Ona G. Montgomery, RN, MSHA, CIC, James Marx, RN, MS, CIC,
               Russell N. Olmsted, MPH, CIC, and William E. Scheckler, MD
                Surveillance in public health is defined as ‘‘the on-                  the frequency of adverse events such as infection or
            going, systematic collection, analysis, interpretation,                   injury. Although the goal of contemporary infection
            and dissemination of data regarding a health-related                      prevention and control programs is to eliminate HAIs,
            event for use in public health action to reduce morbid-                   epidemiologic surveillance is still required for accurate
            ity and mortality and to improve health.’’1 Infection                     quantification of events and demonstration of perfor-
            control professionals apply this definition to both re-                    mance improvement.
            duce and prevent health care–associated infections                            Althoughthereisnosingleor‘‘right’’methodofsur-
            (HAIs) and enhance patient safety. Surveillance, as                       veillance design or implementation, sound epidemio-
            part of infection prevention and control programs in                      logic principles must form the foundation of effective
            health care facilities, contributes to meeting the pro-                   systems and be understood by key participants in the
            gram’s overall goals, namely: (1) protect the patient;                    surveillance program and supported by senior man-
            (2) protect the health care worker, visitors, and others                  agement. Teamwork and collaboration across the
            in the health care environment; and (3) accomplish                        health care spectrum are important for the develop-
            the previous two goals in a timely, efficient, and cost-                   ment of surveillance plans. Rather than institute a
            effective manner whenever possible.2,3                                    ‘‘one size fits all’’ approach to surveillance, each health
                TheAPICfirstpublisheditsRecommendedPractices                           careorganizationmusttailoritssurveillancesystemsto
            for Surveillance in June 1998.4 This revision includes                    maximizeresourcesbyfocusingonpopulationcharac-
            updates related to changing technology and methodol-                      teristics, outcome priorities, and organizational objec-
            ogies, as well as new online resources. Demonstration                     tives. To ensure quality of surveillance, the following
            of quality health care includes documentation of out-                     elements must be incorporated:
            comesofcare.Surveillanceisacomprehensivemethod                            a. Awritten plan should serve as the foundation of any
            of measuring outcomes and related processes of care,                          surveillanceprogram.Theplanshouldoutlineimpor-
            analyzingthedata,andprovidinginformationtomem-                                tantgoals,objectives,andelementsofthesurveillance
            bers of the health care team to assist in improving                           process so that resources can be targeted appropri-
            those outcomes. Surveillance is an essential compo-                           ately. This is commonly integrated into a comprehen-
            nent of effective clinical programs designed to reduce                        sive infection control risk assessment process.
                                                                                      b. Thoroughness or intensity of surveillance for an
              From Department of Epidemiology, Charleston Area Medical Center,            areaofinterestmustbemaintainedatthesamelevel
              Charleston, West Virginia.                                                  overtime.Fluctuationsofasurveillanceratehaveno
              AddressCorrespondencetoTerrieB.Lee,RN,MS,MPH,CIC,Director,                  meaning unless the same level of data collection is
              Epidemiology&EmployeeHealth,CharlestonAreaMedicalCenter,3200                maintained.Externalratecomparisonsarenothelp-
              MacCorkleAvenue,Charleston, WV25304.E-mail:tleewv@msn.com.
              AmJInfect Control 2007;35:427-40.                                           ful and potentially misleading unless the systems
              0196-6553/$32.00                                                            used have comparable intensity.
              Copyright ª 2007 by the Association for Professionals in Infection      c. All the elements of surveillance should be used
              Control and Epidemiology, Inc.                                              with consistency over time; this includes applica-
              doi:10.1016/j.ajic.2007.07.002                                              tion of surveillance definitions and rate calculation
                                                                                          methods.
                                                                                                                                                      427
          428 Vol. 35 No. 7                                                                                        Lee et al
          d. Personnel resources need to be appropriate for the          RECOMMENDEDPRACTICEI
             type of surveillance being performed; this includes         Assessing the population
             trainedprofessionalswhounderstandepidemiology
             andsurveillance and who have access to continuing              Each organization serves different types of patients
             professional education opportunities.                       who are at varied risks for health outcomes (both
          e. Other resources essential to surveillance include           negative and positive). Development of surveillance
             computer support, information and technology                systems should be based on evaluation of the popula-
             services, clerical services, and administrative under-      tions of interest. Such a risk assessment is critical so
             standing and support to maintain a quality program.         that resources can be targeted at populations who are
             Theuseofspecialinfectioncontrolsoftware,orself-             at risk for the outcomes of greatest importance. This,
             formatted spreadsheets or databases can greatly             in turn, enables clinicians to use surveillance informa-
             facilitate many aspects of the surveillance process,        tion to enhance and improve care provided to those
             includingcompilingandmanagementofdata,statis-               targeted populations.
             tical analysis (eg, trend and comparative analysis,
             stratification, significance testing), graphical presen-      Practical applications
             tation, and report generation.                              1. Obtaininformationtodescribeandunderstandpop-
          f. The surveillance program (including surveillance               ulation characteristics. The following questions may
             processes and data), as part of the overall infection          assist in the assessment of a patient population:
             prevention and control program, should be evaluated
             at least annually. Evaluation methods may include              d What types of patients do we serve?
             qualitative assessments, but should also be based on           d What are the most common diagnoses?
             quantitative changes (eg, improvements or decline in           d What are our most frequently performed surgical
             rates). Discontinuing surveillance of outcomes and/or            or other invasive procedures?
             processes that have remained stable and essentially            d Which services or treatments are used most
             unchangedovertimeshouldbeconsideredtoallocate                    frequently?
             resources to address risks with higher priority.               d Are there services or treatments that increase risk
                                                                              of infection for the patient?
             Thisdocumentisintendedtoassistprofessionalswho                 d What types of patients increase liability and/or
          planandconductsurveillanceprogramsaswellasthose                     costs for the organization?
          whoassurethatthereisappropriateorganizationalsup-                 d Does the organization’s strategic plan focus on
          port to accomplish appropriate surveillance. Although               particular groups of patients?
          design of surveillance systems must be unique for each            d What types of health concerns exist in the com-
          organization, incorporation of these seven core Recom-              munity, region, or regulatory environment?
          mendedPractices for Surveillance provides a scientific             d Which patients are at increased risk for infection
          frameworktoapproachsurveillanceprograms.Inaddi-                     or other important outcome?
          tion, expertise in surveillance methodologies will assist      Thoughnotaddressedhere,ageneralknowledgeofrisk
          the infection prevention and control professional              factors for infection and other outcomes is essential.
          whenaddressingissuesrelatedtosystemsthatperform                Suchinformationshouldbeobtainedfromtheliterature
          inter-facilitycomparisons.(eg,publicreportingofhealth          andothertrainingsources.Similarassessmentquestions
          care outcomesorotheraggregatedatabases.)                       should be forumulated for surveillance of other organi-
             Thepurposeofthisdocumentistoprovideaframe-                  zational subpopulations such as health care workers.
          workforthe development of epidemiologic-based sur-             2. As appropriate, use organization-specific sources
          veillance systems for use in health care settings; it is          to obtain population information. Sources might
          notintendedasanindependenteducationalortraining                   include the following:
          document. The following recommendations are based
          on a synthesis of current experience and knowledge                d Medical records
          ofsurveillance,aswellaspublicationsinpeer-reviewed                d Financial services
          journals.                                                         d Information services
             Surveillance planning may not always proceed in                d Quality/utilization management
          the sequential order presented here. However, organi-             d Surgical database
          zationsshouldensurethatallofthefollowingpractices                 d Administrative/management reports
          are incorporated into each surveillance plan. These               d Risk management
          Recommended Practices for Surveillance have been                  d Public health reports
          mostthoroughlyappliedtoHAIs,buttheyareappropri-                   d Community agencies
          ate for any health care outcome or process.                       d Occupational/employee health
                  Lee et al                                                                                     September 2007 429
              d Human resources records                                     of stay) or positive (eg, patient satisfaction). A process
              d Marketing reports                                           istheseriesofstepstakentoachieveanoutcome(eg,im-
           3. Conduct population risk assessment in conjunction             munization, use of patient restraints, compliance with
              withselectingtheoutcomeorprocess(see‘‘Selecting               policies associated with a given outcome). Outcomes
              the outcome or process for surveillance’’ section             and processes included in a surveillance plan should
              below)toestablish priorities for surveillance.                bethosethat have the most important relevance to the
                                                                            population served. This selection process should occur
           Examples                                                         in conjunction with population assessment (see ‘‘As-
                                                                            sessing the population’’ section above). Decisions may
           1. Hospital A is a 1500-bed tertiary care medical center         bebasedonmorbidity,mortality,cost,orotherparame-
              offering a wide range of inpatient and outpatient             ters. Legislative, regulatory, or accrediting organizations
              services. There are six critical care units (medical,         as well as corporate or network entities may have addi-
              surgical, coronary,neurosurgical,pediatrics,andne-            tional requirements for surveillance activities that may
              onatal). The open heart surgery program is one of             affect the relative priority of surveillance objectives.
              thelargestinthecountry.Thereisalargeorthopedic
              surgery program and a predominant gynecology                  Practical applications
              service as well. An analysis of surgical procedures           1. Select outcomes or associated processes for surveil-
              data from the operating room database reveals that                lance based on organizational and patient popula-
              coronary artery bypass graft (CABG) procedures, or-               tion risk assessment. Consider the following:
              thopedicjointreplacements,andhysterectomiesare
              amongthemostcommonlyperformedsurgicalpro-                        d Relative frequency of the event
              cedures. Outpatient medical records indicate that                d Cost or impact of the negative outcome, such as
              primary care is available in the clinic setting, with               treatment costs, length of stay, functional status,
              large numbers of participants in both the pediatrics                qualityoflife,mortality,severitymeasures,andlit-
              and geriatrics populations.                                         igation and/or public relations risks
           2. Hospital B is a 75-bed acute care hospital in a rural            d Potential for surveillance information to contrib-
              setting. Medical records show that most admissions                  ute to prevention activities
              are adult patients with a variety of acute medical di-           d Customer needs (eg, priorities set by the health
              agnoses. General surgical procedures are performed                  care team)
              by the two staff surgeons, with cholecystectomies,               d Communityserved(eg,healthneedsofthepatient
              hysterectomies, and hernia repairs the most fre-                    population)
              quently performed. Some nursing personnel have                   d Organizational mission and strategic goals
              reported that many patients may have had indwell-                d Strength of association between process and
              ing urinary catheters longer than necessary or with-                important outcome
              out a clear indication for use. One health problem               d Microbiology      data   and/or   antimicrobial    use
              noted by the local public health department is a re-                findings
              cent increase in the incidence of tuberculosis (TB).             d Regulatory or accrediting body requirements
           3. A homehealthagencyprovidescaretoawiderange                    2. Allocate surveillance resources by directing them
              ofpatients,specializinginintravascularaccess/treat-               toward highest ranked priorities.
              ment with short-term and long-term central lines              3. Re-evaluate resulting surveillance objectives as
              andwithperipherallines.Thereisalsoalargenum-                      needed, at least annually.
              ber of patients with indwelling urinary catheters.
                                                                            Examples
           RECOMMENDEDPRACTICEII                                            1. The following infection surveillance is planned
           Selecting the outcome or process                                     for a calendar year at Hospital A (see Example 1 in
           for surveillance                                                     ‘‘Assessing the population’’ section above):
              Anorganization would rarely find it feasible to con-              d All patients in the intensive care unit will be moni-
           ductorganization-widesurveillanceforallevents.Alog-                    tored for two types of device- associated infec-
           ical method for setting surveillance priorities and                    tions, ventilator-associated pneumonias (VAPs),
           associated resource allocation is essential. The choice                andcentral line–associated bloodstream infections
           of outcomes or processes to be measured defines the                     (CLABSIs). Rationale: high-risk patients, substantial
           surveillance that is appropriate for each measure. An                  opportunity for improvement, can compare with
           outcomeistheresultofcareorperformance.Outcomes                         rates most recently reported by the National Noso-
           maybenegative(eg, infection, injury, increased length                  comial Infections Surveillance/National Healthcare
           430 Vol. 35 No. 7                                                                                           Lee et al
                Safety Network (NNIS/NHSN) of the Centers for                    increased prevalence of TB in community, oppor-
                Disease Control and Prevention (CDC).                            tunity for early detection and intervention.
              d Adherence by personnel with ‘‘bundles’’ (groups                d Use of indwelling urinary catheters will be moni-
                of evidence-based interventions) for prevention of               tored among all patients. Rationale: process asso-
                VAPs and CLABSIs will be monitored. Rationale:                   ciated with infectious outcome.
                processes that are associated with prevention of               d Immunization of appropriate patient care person-
                infectious outcomes.                                             nelforhepatitisBwillbemonitored,aswillannual
              d Surgical site infection (SSI) surveillance will be               influenzavaccinationparticipationrate.Rationale:
                performed on the three most common types of                      processes knowntopreventserious infections.
                surgical procedures:CABG,orthopedicjointreplace-            3. A home health company (see Example 3 in ‘‘Assess-
                ments, and hysterectomies. Rationale: CABG: high-              ingthepopulation’’sectionabove)decidestoinclude
                risk patients, potential forseriousadverseoutcomes,            three types of device-associated infections in the
                frequently occurring procedure, risk management                annual surveillance plan: central line–associated
                concerns; joint replacements: same rationale; hys-             bloodstream infections, peripheral line–associated
                terectomies: frequently occurring procedure. Rates             bloodstream infections, and catheter-associated
                for comparison are available from NHSN. Also,                  urinary tract infections. Patients with intravascular
                nurses have reported a perception that there have              devices will also be monitored for development of
                been numerous surgical site infections in patients             phlebitis. Rationale: potential for improvement of
                undergoing hysterectomy.                                       high-risk device-related outcomes.
              d Antibiotic prophylaxis will be monitored as a pro-
                cess measure among the same surgical popula-
                tions, with a focus on antibiotic delivery timing.          RECOMMENDEDPRACTICEIII
                Rationale: process known to be associated with              Using surveillance definitions
                preventing the outcome of SSI.
              d Immunizationrates will be monitored in the inpa-               In any surveillance system, all data elements should
                tient settingsandoutpatientmedicalandpediatrics             be clearly defined. This includes the outcome or pro-
                clinics.Forpediatrics,state-requiredchildhoodim-            cess,‘‘at-risk’’ population, and risk factors. Valid defini-
                munizationswillbeincluded.Foradults,thefocus                tions   will   enhance consistency,       accuracy,    and
                will be on influenza and pneumococcus vaccina-               reproducibility of surveillance information.
                tions amonghigh-riskpopulations.Rationale:pro-
                cess that is known to prevent serious infections,           Practical applications
                required information for primary care monitoring            1. Use standardized written case definitions to ensure
                as well as a quality indicator for the Centers for             precisesurveillance.Whereavailableandapplicable,
                MedicareandMedicaidServices.                                   use previously published, validated definitions.
           2. The annual infection surveillance plan for Hospital              Thesemaybeobtainedfromfederalagencies,regu-
              B(see Example 2 in ‘‘Assessing the population’’ sec-             latorybodies,andprofessionalorganizations.Where
              tion above) will include the following components:               not available, prepare written definitions to ensure
                                                                               intra-organization standardization. For accurate and
              d SSI surveillance will be performed for cholecys-               valid comparisons of data, use the same definitions
                tectomies, hysterectomies, and hernia repairs.                 over time.
                Because the number of procedures is so low, rate            2. When historical data are used for internal compari-
                calculations may be needed only annually or                    sons or for external comparisons, ensure that the
                perhaps less frequently. Although the infection                same definitions are used for outcomes and pro-
                control professional (ICP) will keep aware of SSIs,            cesses and that populations are at similar risk.
                there is no plan to calculate infection rates for           3. If definitions are changed, be aware that such
                other types of infections, because infections                  changes compromise the comparability of rates
                occur too infrequently and the numbers are too                 over time. This information should be highlighted
                small to be meaningful. Rationale: focus on the                whenreporting data to avoid misinterpretation.
                most frequent surgical procedures, can compare
                rates to those reported by CDC’s NNIS/NHSN                  Examples
                system.
              d TB skin-testing compliance rates will be moni-              1. The ICPat an acute care hospital decides to conduct
                tored among all staff, as well as among patients               surveillance for primary bloodstream infections as-
                inhigh-riskpopulations.Skintestconversionrates                 sociated with the use of central lines in the surgical
                will also be followed among staff. Rationale:                  intensive care unit (SICU) patients. To be able to