Pick Your Battles: Conducting Efficient & Effective Targeted Surveillance in Your Facility
At the SHEA Spring 2017 Conference, Laurie Conway, RN, PhD, CIC, provided conference goers with options that will allow them to “pick their battles” when it comes to ensuring effective surveillance targets.
At the Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference in St. Louis, MO, Laurie Conway, RN, PhD, CIC, delivered a presentation explaining that, infection preventionists (IPs) need to “pick their battles,” when it comes to surveillance targets. She also shared with a room full of conference attendees some ways to ensure effective surveillance efforts.
“Surveillance takes up about 44% of our time, so we need to choose wisely when we say we are going to monitor and act on something. Only about one third of hospitals use electronic surveillance systems, so when it comes to picking our battles, we’re talking about how we’re going to spend our personal IP time,” Dr. Conway said. She reminded attendees that having rational surveillance targets is a “core component of any Infection Prevention and Control (IPAC) program and mandatory surveillance targets are usually chosen due to “their preventability and ease of comparison, not local risk.”
There are two ways to choose surveillance targets according to Dr. Conway: regulatory mandates and formal risk assessments. For the United States, Dr. Conway shared that there are regulatory mandates in place for central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), Clostridium difficile infections (CDI), methicillin-resistant Staphylococcus aureus (MRSA), healthcare worker (HCW) vaccination, and ventilator-associated events (VAE); however, there are different regulated surveillance targets for different types of facilities.
“This is a huge list and that alone can take up all of your time,” Dr. Conway said.
In addition to federal mandates, there are also state mandates that are updated regularly. According to Dr. Conway, they can be accessed via the APIC website simply by searching for public policy; each state has different reporting requirements.
“So, now we’re dictated to in a big way, but we also know we have local risks,” she said. “To identify these risks, and be able to say ‘yes’ to some, and ‘no’ to others, we have to conduct a formal risk assessment,” or infection control risk assessments (ICRAs). ICRAs are to be done each year to assess hazards based on: “the community that you serve, the services you provide, what services are building, what [ones] are winding down as well as the case mix that provides.” Furthermore, existing healthcare-associated infection rates should also be considered, as well as any notable trends. She also mentioned the importance of an antibiogram: “Is resistance changing? Are there organisms and pathogens that you should start monitoring or stop monitoring?” Lastly, the infrastructure of your facility needs to be taken into consideration.
Dr. Conway discussed two tools that can be utilized to complete these risk assessments.
The first is an ICRA tool that can be accessed through the Centers for Disease Control and Prevention (CDC) website or through the APIC website. The ICRA is “an excel file already set up for you” that “lists all risks for each row, and then the column headers are your assessment of whether you have zero risk, low, medium, or high risk, and what the risk is, what level of risk you’re at, what you already have in place to deal with it, and what resources would be required.” Finally, the tool generates a percentage to highlight the likelihood of a risk. Within this larger risk assessment, they also have smaller risk assessment tools available online, such as the Tuberculosis Risk Assessment Tool, which “asks questions that would be useful for you to ask every year, such as: ‘Are patients with suspected or confirmed TB disease encountered in your setting? How often? How many present to your emergency department?’” Dr. Conway said that this tool will help you assess if there is a low, medium, or high risk of TB.
The second is the Infection Control and Response (ICAR), which was designed in part by the CDC for state inspections; it can also be used so that “you can inspect yourself.” Dr. Conway continued, “It is long, but it is actually more intuitive than the excel spreadsheet to assess your program.”
“So, you’ve got your mandated surveillance, and then you’ve got your surveillance based on your risks, and it’s always going to be too much. So, now you have to decide, ‘we’re going to conduct surveillance, but some of it’s going to have to be modified,’” Dr. Conway said. She continued to share with attendees four effective and efficient ways to conduct targeted surveillance in their own facilities.
1. Narrow your surveillance to your highest risk targets.
Using a point prevalence survey, you can better identify where your biggest problem is, and then just collect data pertaining to your problem area. “So, instead of collecting data on all CLABSIs in your center, just collect data on CLABSIs in oncology; if that’s where your problem is, then only collect data there,” she explained. The only drawback that comes with “very targeted surveillance” is “very small numerators.” Dr. Conway’s solution? “Take your time and surveil them for two years. You can always intervene along the way, especially in a staged way.”
2. Use simple surveillance definitions consistently.
She reminded conference attendees that they do not have to use the CDC’s National Healthcare Safety Network’s (NHSN) definitions “if you don’t want to and it doesn’t work for you.” She continued, “Yes, if you need a really good baseline and a good comparator, then definitely use NHSN definitions, but if it’s not simple for you to use those, then use really simple definitions for yourself.” Another route that can be taken, according to Dr. Conway, is utilizing simplified definitions provided by the World Health Organization for healthcare-associated infections for developing countries.
3. Surveil outcomes and processes together.
By doing this, you’ll “have two beautiful sets of data for one effort,” Dr. Conway explained. “So, for instance, CAUTI and device utilization; you double the utility of collecting denominator data. Honestly, CAUTI is almost never the priority, but it is for our regulators; priority is usually device utilization [and] catheter utilization, so monitor them together.”
4. Accept any target that a clinician is already motivated to improve.
What are the benefits to doing this? Dr. Conway explained, “This saves you time, because as you know, half your time as an IP, or hospital epidemiologist, is spent convincing people that this is important to monitor, that it is important to use the monitoring data and act on it to reduce infections.” She added, “Well, if they are already halfway there, then just jump on the wagon with them.” She provided attendees with an example of how, at her own facility, external ventricular drain (EVD) infections were higher than they wanted it to be. However, according to Dr. Conway, she had a clinician group (ranging from nurse practitioners to nurse educators to intensivists to neurosurgeons) who were “highly motivated” and all wanted the same thing: to reduce EVD infections. Also, the clinician group already suspected certain risk factors or practices. “So, all I needed to do was come in and support them. I helped them find benchmarks for outcome surveillance. I helped them identify best practices for the process of surveillance, because that’s where my expertise lies… They give me a ton of contextual information that I barely have to ask for,” Dr. Conway said. “And goal setting; they set their goals themselves, almost. So, I think this is a really wise use of our resources at this setting.”
She concluded, “We all know that surveillance is very labor-intensive; it uses a lot of our resources and our resources are limited. Regulators do dictate some surveillance activities, but a surveillance plan, our own plan, should be based on our own risk assessment in our own location, and there are some options that I’ve suggested for sufficient surveillance.”
By taking advantage of some of these options, infection preventionists and hospital epidemiologists alike can “pick their battles" and make the most of their time in resource-limited settings.
2017 SHEA Spring Conference
Picking Battles: Balancing ICRA versus Regulatory Mandates