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 Although there is no single or ‘‘right’’ method of sur- (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 The APIC first published its Recommended Practices care organization must tailor its surveillance systems to for Surveillance in June 1998.4 This revision includes maximize resources by focusing on population charac- 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: comes of care. Surveillance is a comprehensive method of measuring outcomes and related processes of care, a. A written plan should serve as the foundation of any analyzing the data, and providing information to mem- surveillance program. The plan should outline impor- bers of the health care team to assist in improving tant goals, objectives, and elements of the surveillance those outcomes. Surveillance is an essential compo- process so that resources can be targeted appropri- nent of effective clinical programs designed to reduce ately. This is commonly integrated into a comprehen- sive infection control risk assessment process. b. Thoroughness or intensity of surveillance for an From Department of Epidemiology, Charleston Area Medical Center, area of interest must be maintained at the same level Charleston, West Virginia. over time. Fluctuations of a surveillance rate have no Address Correspondence to Terrie B. Lee, RN, MS, MPH, CIC, Director, Epidemiology & Employee Health, Charleston Area Medical Center, 3200 meaning unless the same level of data collection is MacCorkle Avenue, Charleston, WV 25304. E-mail: [email protected]. maintained. External rate comparisons are not help- Am J Infect Control 2007;35:427-40. ful and potentially misleading unless the systems used have comparable intensity. 0196-6553/$32.00 c. All the elements of surveillance should be used Copyright ª 2007 by the Association for Professionals in Infection Control and Epidemiology, Inc. with consistency over time; this includes applica- tion of surveillance definitions and rate calculation doi:10.1016/j.ajic.2007.07.002 methods. 427 428 Vol. 35 No. 7 Lee et al d. Personnel resources need to be appropriate for the RECOMMENDED PRACTICE I type of surveillance being performed; this includes Assessing the population trained professionals who understand epidemiology and surveillance 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 The use of special infection control software, or self- 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 including compiling and management of data, statis- targeted populations. tical analysis (eg, trend and comparative analysis, stratification, significance testing), graphical presen- Practical applications tation, and report generation. f. The surveillance program (including surveillance 1. Obtain information to describe and understand pop- processes and data), as part of the overall infection ulation characteristics. The following questions may prevention and control program, should be evaluated assist in the assessment of a patient population: 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 unchanged over time should be considered to allocate frequently? resources to address risks with higher priority. d Are there services or treatments that increase risk of infection for the patient? This document is intended to assist professionals who d What types of patients increase liability and/or plan and conduct surveillance programs as well as those costs for the organization? who assure that there is appropriate organizational sup- 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? mended Practices for Surveillance provides a scientific d Which patients are at increased risk for infection framework to approach surveillance programs. In addi- or other important outcome? tion, expertise in surveillance methodologies will assist the infection prevention and control professional Though not addressed here, a general knowledge of risk when addressing issues related to systems that perform factors for infection and other outcomes is essential. inter-facility comparisons. (eg, public reporting of health Such information should be obtained from the literature care outcomes or other aggregate databases.) and other training sources. Similar assessment questions The purpose of this document is to provide a frame- should be forumulated for surveillance of other organi- work for the development of epidemiologic-based sur- zational subpopulations such as health care workers. veillance systems for use in health care settings; it is 2. As appropriate, use organization-specific sources not intended as an independent educational or training to obtain population information. Sources might document. The following recommendations are based include the following: on a synthesis of current experience and knowledge d Medical records of surveillance, as well as publications in peer-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 zations should ensure that all of the following practices d Administrative/management reports are incorporated into each surveillance plan. These d Risk management Recommended Practices for Surveillance have been d Public health reports most thoroughly applied to HAIs, but they are appropri- 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 is the series of steps taken to achieve an outcome (eg, im- 3. Conduct population risk assessment in conjunction munization, use of patient restraints, compliance with with selecting the outcome or process (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) to establish priorities for surveillance. be those that 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’’