Feeding Back Surveillance Data To Prevent Hospital-Acquired Infections.According to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. a 1996 Institute of Medicine (IOM IOM
See: Index and Option Market ) report, preventable "adverse health events," a category defined as injuries such as medical errors (a failure of planned actions) and hospital-acquired infections Hospital-Acquired Infections Definition
A hospital-acquired infection is usually one that first appears three days after a patient is admitted to a hospital or other health care facility. caused by medical interventions, are responsible for 44,000 to 98,000 deaths per year at a cost of $17-$29 billion (1). The IOM report recommended immediate and strong mandatory reporting mandatory reporting The obligatory reporting of a particular condition to local or state health authorities, as required for communicable disease and substance abuse Infectious disease State boards of health maintain records and collect data resulting from MR of of medical errors and voluntary reporting of other adverse health events, suggesting that monitoring leads to reduction. A hallmark: of monitoring any adverse health event is reporting the information back to those who need to know. We examine the value of feeding back information on hospital-acquired infections to reduce and prevent them.
Hospital-Acquired Infections Surveillance Systems as a Model to Monitor and Prevent Other Adverse Health Events
Hospital-acquired infections affect approximately 2 million persons each year (2). Such infections have been monitored in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. since the 1970s, and the monitoring is often a model for monitoring other adverse health events (3). Principles used in the surveillance of hospital-acquired infections are strikingly similar to those used in the continuous quality improvement process in manufacturing (4). Both systems emphasize changes at the system rather than individual level. Deming described two types of errors in manufacturing: special causes and usual causes. Special causes of error comprise only 5% to 10% of all errors; usual causes constitute the remainder. Similarly, only 5% to 10% of hospital-acquired infections occur in recognized outbreaks (4,5).
Surveillance Systems for Hospital-Acquired Infections
Surveillance is defined as "the ongoing, systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination dissemination Medtalk The spread of a pernicious process–eg, CA, acute infection Oncology Metastasis, see there of these data to those who need to know" (6). The scientific value of surveillance as part of a hospital infection-control program was demonstrated most strongly in the landmark Study of the Efficacy of Nosocomial Infection Nosocomial infection
An infection that can be acquired in a hospital. ABPA is a nosocomial infection.
Mentioned in: Allergic Bronchopulmonary Aspergillosis, Hospital-Acquired Infections, Pseudomonas Infections
Control (SENIC) (2). In that study, highly trained data collectors evaluated more than 338,000 patient records from a probability sample of U.S. hospitals to calculate infection rates. The hospitals' control programs were also evaluated. SENIC found that hospitals with the lowest nosocomial infection rates had strong surveillance and prevention programs. Other studies have suggested that surveillance also has a strong scientific basis. For example, the collection, calculation, and dissemination of surgeon-specific, surgical site infection (SSI (1) See server-side include and single-system image.
(2) (Small-Scale Integration) Less than 100 transistors on a chip. See MSI, LSI, VLSI and ULSI.
1. (electronics) SSI - small scale integration.
2. ) rates to surgeons were found to reduce SSI rates in all published studies (3,6-9).
During the last two decades, hospitals have established internal systematic monitoring of hospital-acquired infection rates. Monitoring with benchmarks external to those of a single hospital's surveillance system has also been suggested (10). A single hospital may use its own definitions, methods, and monitoring protocols. Developing a monitoring system with external benchmarks requires considerable additional effort.
To be successful, a multicenter monitoring system must satisfy three requirements: it must have a very clear purpose; it must use standard definitions, data fields, and protocols (including of cohorts or groups to be monitored and periods of data collection); and it must identify an aggregating institution to standardize stan·dard·ize
1. To cause to conform to a standard.
2. To evaluate by comparing with a standard. definitions and protocols, receive the data, assess them for quality, standardize the approach to risk-adjusting the benchmarks, and interpret and disseminate dis·sem·i·nate
v. dis·sem·i·nat·ed, dis·sem·i·nat·ing, dis·sem·i·nates
1. To scatter widely, as in sowing seed.
2. the data.
The NNIS NNIS National Nosocomial Infection Surveillance System System
The Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC's) National Nosocomial Infections Nosocomial infections
Infections that were not present before the patient came to a hospital, but were acquired by a patient while in the hospital.
Mentioned in: Enterobacterial Infections, Staphylococcal Infections Surveillance (NNIS) system has been serving as an aggregating institution for 30 years. The NNIS system is a voluntary, hospital-based reporting system established to monitor hospital-acquired infections and guide the prevention efforts of infection control practitioners. In 1999, 285 hospitals in 42 states participated in the NNIS system (11). All NNIS hospitals have [is greater than or equal to] 100 beds and, on average, are larger than other U.S. hospitals (median bed size: 360 versus 210); however, NNIS hospitals have a geographic distribution similar to all other U.S. hospitals. The NNIS system establishes a national risk-adjusted benchmark for nosocomial infection rates and invasive device-use ratios (12,13) by using uniform case definitions and data-collection methods and computerized data entry and analysis. To promote the latter, CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation provides infection control practitioners with 28 hours of training and sponsors a biennial biennial, plant requiring two years to complete its life cycle, as distinguished from an annual or a perennial. In the first year a biennial usually produces a rosette of leaves (e.g., the cabbage) and a fleshy root, which acts as a food reserve over the winter. conference.
Patients in intensive-care units (ICUs) are at high risk for nosocomial infections and since 1987 have been monitored in the NNIS system by site-specific, risk-adjusted infection rates according to ICU ICU intensive care unit.
intensive care unit
see intensive care unit.
ICU type (12). The risk-adjusted benchmark infection rates and device-use ratios are published annually for use by both NNIS and non-NNIS hospitals (12). (Internet address There are two kinds of addresses that are widely used on the Internet. One is a person's e-mail address, and the other is the address of a Web site, which is known as a URL. Following is an explanation of Internet e-mail addresses only. For more on URLs, see URL and Internet domain name. for NNIS SemiAnnual Semiannual
An event that occurs twice in a calendar year.
A bond with semiannual coupons would issue payment once every six months.
See also: Annual, Bond, Coupon Bond Report: http://www.cdc.gov/ncidod/hip/surveill/NNIS.htm).
For an aggregating institution to assess the quality of data, meaningful surveillance definitions of adverse health events must be available. These definitions do not define clinical illness; rather, they are used for credible, consistent application across institutions. There is always a balance between the resources expended ex·pend
tr.v. ex·pend·ed, ex·pend·ing, ex·pends
1. To lay out; spend: expending tax revenues on government operations. See Synonyms at spend.
2. to find these cases and the value within the institution of using the collected data and comparing them to the external benchmarks. There is no single source of information that allows an infection control practitioner to accurately identify hospital-acquired infections. CDC definitions of nosocomial infections include clinical and laboratory information that requires training, counseling, and updating--tasks that are largely the responsibility of the aggregating institution. Several studies have examined attempts at shortcuts See Win Shortcuts. around the training and counseling components; all studies suggest that medical record abstractors perform very poorly compared with infection control practitioners in case-finding for nosocomial infections (9). Hospital-acquired infection case ascertainment is time-consuming, and the process is becoming more difficult with earlier discharge of patients and lack of agreement on methods of postdischarge surveillance (14,15). Progress in this area has been slow, and more efficient methods of case ascertainment are needed. Sands et al. have proposed using exposure to antimicrobial antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al)
1. killing microorganisms or suppressing their multiplication or growth.
2. an agent with such effects. drugs as a sensitive method for finding cases of SSI in the postdischarge outpatient setting (16). Although this method is efficient, many institutions are unable to acquire antimicrobial-drug use data for outpatients who have recently undergone hospital surgical procedures Surgical procedures have long and possibly daunting names. The meaning of many surgical procedure names can often be understood if the name is broken into parts. For example in splenectomy, "ectomy" is a suffix meaning the removal of a part of the body. "Splene-" means spleen. . Finally, despite current difficulties, a recent study in NNIS hospitals suggests accurate case finding can be achieved (Table 1).
Table 1. Estimates of accuracy of prospectively reported infections in nine NNIS Hospitals(a) Predictive value positive Sensitivity Specificity Infection site (%) (%) (%) Bloodstream 87 85 98.3 Pneumonia 89 68 97.8 Surgical site 72 67 97.7 Urinary tract 92 59 98.7 Other 80 30 98.6 (a) Adapted from Emori TG, et al. Infect Control Hosp Epidemiol (17).
Measuring Infection Rates: Endemic- or Epidemic-Disease Rates?
Surveillance measures the endemic-disease rate of nosocomial infection. Less than 10% of all nosocomial infections occur in recognized outbreaks (5). If an outbreak occurs in a hospital, it is often because one prevention strategy failed for a short period. The endemic-disease rate provides hospitals with knowledge of the ongoing infection risks of hospitalized patients when no recognized outbreaks are occurring. This rate represents 90% to 95% of all hospital-acquired infections (5). Thus, ongoing surveillance measures the endemic-disease rate. Unlike outbreaks, rates established by ongoing surveillance usually require that many problems be addressed to lower a high rate of infection.
Measuring Success in a Surveillance System
From 1990 through 1999, we examined risk-adjusted, hospital-acquired infection rates used by participating NNIS hospitals (18). We found that decreases in risk-adjusted infection rates occurred at all three body sites (respiratory tract respiratory tract
The air passages from the nose to the pulmonary alveoli, including the pharynx, larynx, trachea, and bronchi.
Respiratory tract , urinary tract, and bloodstream blood·stream
The flow of blood through the circulatory system of an organism.
the blood flowing through the circulatory system in the living body. ) monitored in ICUs (18). Substantial decreases in bloodstream infection rates occurred in medical (44%), surgical (31%), and pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. (32%) ICUs (Figure). Decreases also occurred in other ICU types (Table 2) and in infection rates at other sites (18). The reasons for these decreases are unknown, but several explanations are possible. First, the improvements seen in NNIS hospitals also reflect other national efforts to prevent infections (e.g., new research findings, prevention guidelines). Second, the U.S. health-care system has shifted away from hospital-based care. Some of the observed rate reductions could be attributable to this shift. However, a portion of these observed decreases likely represented true decreases in hospital-acquired infection rates in NNIS hospitals. Disseminating risk-adjusted, reliable infection rates within NNIS hospitals to infection control practitioners, patient care givers, and administrators was an essential part of NNIS efforts during the 1990s. By all reports, patient-care personnel began to perceive value in the data, relied on them for decisions, and altered their behavior in ways that may have reduced the incidence of nosocomial infections in NNIS hospitals. By changing the behavior of patient care givers, the NNIS approach to surveillance of nosocomial infections may have actually improved the quality of patient care. This report (18) demonstrated the value of the NNIS system as a model for preventing hospital-acquired infections (18).
[Figure ILLUSTRATION OMITTED]
Table 2. Decrease in hospital-acquired infection rates, NNIS, 1990-1999 Ventilator- Urinary Bloodstream associated tract infection pneumonia infection Type of ICU rate(a) (%) rate (%) rate(b) (%) Coronary 43 42 40 Medical 44 56 46 Surgical 31 38 30 Pediatric 32 26 59 (a) Central line associated. (b) Catheter associated.
Critical Elements of a Surveillance System for Hospital-Acquired Infections
The NNIS elements critical for successful reductions in infection rates included 1) voluntary participation and confidentiality; 2) standard definitions and protocols; 3) defined populations at high risk (e.g., intensive care, surgical patients); 4) site-specific, risk-adjusted infection rates comparable across institutions; 5) adequate numbers of trained infection control practitioners; 6) dissemination of data to health-care providers; and 7) a link between monitored rates and prevention efforts, where patient-care personnel relied on the data to alter their behavior in ways that may have reduced the incidence of nosocomial infections (17).
Challenges for the NNIS System's Future
Despite NNIS' success, many challenges remain. The IOM report recommends mandatory reporting of medical errors (1). Others have advocated public availability of such information. But achieving accurate data may be difficult if mandatory reporting and public availability of these data are required in all circumstances. These requirements heighten height·en
v. height·ened, height·en·ing, height·ens
1. To raise or increase the quantity or degree of; intensify.
2. To make high or higher; raise.
v.intr. the need to assess the accuracy of self reported data from institutions, a process that is difficult and expensive. The demand for publicly available data is particularly troubling. The NNIS Evaluation Study has suggested that, while data on nosocomial infections are generally accurately reported, sensitivity (underreporting of infections) was a more serious problem than other measures of accuracy such as predictive value pre·dic·tive value
The likelihood that a positive test result indicates disease or that a negative test result excludes disease.
a measure used by clinicians to interpret diagnostic test results. positive or specificity (17). When the added pressure of publicly available data is added to a process that already has a tendency to miss cases of nosocomial infection, the possibility of serious underreporting of infections becomes cause for concern. Validating data is essential if data from performance measurement systems are to be credible.
All segments of the health-care community may not want or need the same data or the same level of detail in the data. Take the example of a consumer purchasing an automobile. The consumer rightly anticipates that the car will have a braking system that is safe and fully operational and thus would find
the rate of errors for brake installation from the manufacturer of limited interest. This rate of error would be of vital interest to the manufacturer, however. Similarly, it is doubtful that regulators, payers, the public, or the health-care institution all want the same information with the same level of detail.
The medical marketplace is very dynamic. Surveillance must also be dynamic to keep pace with the changing environment. Improved methods of case ascertainment, especially with regard to postdischarge and outpatient surveillance, will be needed as more health care is provided outside the hospital. Improvement in measures of intrinsic and extrinsic EVIDENCE, EXTRINSIC. External evidence, or that which is not contained in the body of an agreement, contract, and the like.
2. It is a general rule that extrinsic evidence cannot be admitted to contradict, explain, vary or change the terms of a contract or of a patient risk factors will also be needed for improved risk adjustment. As computerization com·put·er·ize
tr.v. com·put·er·ized, com·put·er·iz·ing, com·put·er·iz·es
1. To furnish with a computer or computer system.
2. To enter, process, or store (information) in a computer or system of computers. and integration of health care continue, these improvements will be possible. However, sound epidemiologic principles used by knowledgeable workers must guide use of the new technologies. A key to NNIS's success is infection control practitioners who use monitoring data to implement prevention activities. Any new system for preventing adverse health events will need to develop a cadre (company) CADRE - The US software engineering vendor which merged with Bachman Information Systems to form Cayenne Software in July 1996. of professionals at the health-care facility to design and implement the prevention programs to promote patient safety and health-care quality (19).
Demonstrating the value of surveillance data to both the hospital's patient-care personnel and administration is essential. However, patient-care personnel must perceive value in the data; if they do, they will rely on the data for decisions and alter their behavior in ways that should reduce the incidence of nosocomial infections. By changing the behavior of care givers, surveillance of nosocomial infections or other adverse health events can improve the quality of patient care. However, SENIC suggested that only approximately one third of nosocomial infections are preventable (2). Better measures of adverse health events, including of nosocomial infections that are truly preventable, will make this monitoring more efficient and useful (20). Prevention measures will help move nosocomial infections from adverse health events to what the IOM described as medical errors (1). Solving the problem of medical errors still has its challenges.
Better understanding of the inner workings of the health-care delivery system to determine the root cause of errors is needed. Additionally, consistently good performers in a system where interhospital comparison of rates has been performed can identify the best practices. We are only beginning to understand the multiple prevention efforts of these high performers and how they differ from those of other institutions.
Despite the difficulties and challenges, application of epidemiologic principles can lead to success. A surveillance system to monitor hospital-acquired infections requires standardization standardization
In industry, the development and application of standards that make it possible to manufacture a large volume of interchangeable parts. Standardization may focus on engineering standards, such as properties of materials, fits and tolerances, and drafting , targeted monitoring, risk adjustment, trained professionals, and a link between the disseminated data and prevention efforts. A system such as the NNIS system with all these critical elements can be successful in preventing infections.
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(2.) Haley RW, Culver cul·ver
A dove or pigeon.
[Middle English, from Old English culufre, from Vulgar Latin *columbra, from Latin columbula, diminutive of columba, dove.] DH, Morgan WM, Emori TG, Munn VP, Hooton TP. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985;121:182-205.
(3.) Cruse PJE PJE Policía Judicial del Estado (México)
PJE Parachute Jumping Exercise
PJE Program for Joint Education , Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980;60:27-40.
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(10.) Sherertz RJ, Garabaldi RA, Kaiser AB, Marosal R, Berg RM, Gaynes RP, et al. Consensus paper on the surveillance of surgical wound infections. Infect infect /in·fect/ (in-fekt´)
1. to invade and produce infection in.
2. to transmit a pathogen or disease to.
1. Control Hosp Epidemiol 1992;13:599-605.
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Payment made to someone for out-of-pocket expenses has incurred. . Am J Public Health 1987;77:561-4.
(15.) Holtz T, Wenzel R. Postdischarge surveillance for nosocomial nosocomial /noso·co·mi·al/ (nos?o-ko´me-il) pertaining to or originating in a hospital.
1. Of or relating to a hospital.
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(17.) Emori TG, Edwards JR, Culver DH, Sartor C, Stroud stroud
A coarse woolen cloth or blanket.
[After Stroud, an urban district of southwest-central England.] LA, Gaunt gaunt
thin plus obvious diminution in abdominal size, indicative of reduced feed intake leading to reduced gut fill. EE, et al. Accuracy of reporting nosocomial infections in intensive care unit patients to the National Nosocomial Infections Surveillance (NNIS) system: A pilot study. Infect Control Hosp Epidemiol 1998;19:308-16.
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(19.) Scheckler WE, Brimhall D, Buck AS, Farr BM, Friedman C, Garibaldi RA, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Am J Infect Control 1998;26:47-60.
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Dr. Gaynes is deputy chief, Healthcare Outcomes Branch, Division of Healthcare Quality Promotion, National Center for Infectious Diseases infectious diseases: see communicable diseases. , CDC, and has been director of the NNIS system for 11 years. His main research interests are health-care acquired infections and antimicrobial-drug resistance.
Address for correspondence: Robert Gaynes, Hospital Infections Program, Centers for Disease Control and Prevention, 1600 Clifton Road Clifton Road is main street in Clifton neighborhood of Saddar Town in Karachi, Sindh, Pakistan.
Its name dates from the British Colonial rule, and its market is posh areas of Karachi. , Mailstop E55, Atlanta, GA 30333; fax: 404-639-6458; e-mail: email@example.com