Surveillance is crucial to LTC infection control

The need for surveillance activities is well-documented in JCAHO standards, participation requirements from the Centers for Medicare & Medicaid Services, and national standards of practice.

These surveillance activities come in two varieties:

Be alert to your state surveyors' expectations regarding the type of surveillance, but ultimately "your facility determines what type of surveillance you use," Bennett said.

There are several methods of finding infections in your facility:

Collectible data includes the resident's name, record number, physician, admission date, symptoms and onset, site of infection, culture date/pathogen, and risk factors.

To determine whether an infection is present, consult Definitions of Infection for Surveillance in Long-term Care Facilities, also known as the McGeer definitions. This document was developed by a group of IC experts led by Allison McGeer and published in 1991 in the American Journal of Infection Control. Download the document at www.apic.org/pdf/ltcdefs.pdf

The group developed these definitions because it believed the standard definitions of HAIs for acute-care hospitals were not applicable for most long-term care facilities.

According to the document's introduction, the definitions are intended specifically for use in facilities that provide homes for elderly residents requiring 24-hour personal care under professional nursing supervision. The majority of residents have some degree of mental impairment, and all require some assistance with daily living activities. They may require urinary catheters, sterile dressings, or tube feedings, but neither intravenous therapy nor laboratory/radiology facilities are usually available on the premises.

The following three conditions apply to all of the definitions, according to the document:

The McGeer document includes definitions for such common infections as respiratory tract infections; eye, ear, nose, and mouth infections; skin infections; gastrointestinal tract infections; and systemic infections.

When examining infection data, look for the following:

When tracking trends, make bar graphs of infections and watch to see whether certain problems develop, Bennett said. Outbreaks require quick identification and action, which makes a good surveillance system that much more important, she notes.

For instance, you may need assistance in handling an outbreak investigation; in most states, the first point of assistance is the local health office, but in some cases the state health department may assist you. Report outbreaks to the health department as required by state law.

To determine HAI rates, divide the numerator (i.e., the number of new cases of infection for the period of review) by one of several denominators (e.g., average census or patient population, total patient or resident days, or device days).

Calculate the general percentage of infection by dividing the number of new cases by the average census and multiplying by 100. For more specific rates, divide the number of new cases by total resident days and multiply by 1000, which gives you the number of infections per 1000 resident days. This is preferred method of calculation if you choose to report an overall rate, Bennett said.

To look at a specific risk factor such as infections acquired from medical devices, divide the number of new cases of urinary tract infections, for example, by the total number of urinary device days (or the number of days patients were on such devices) and multiply by 1,000. This gives you the number of urinary tract infections per 1,000 urinary device days. Methods of presenting the data you collect include a monthly summary of infections and colorful reports with tables, graphs, and charts.

The facility's performance improvement (PI) activities must examine the process and methods used for data collection, data analysis description, and reporting formats, said Ruth Ann Rye, RN, BS, CIC, an independent IC consultant. In addition, the PI process involves making recommendations for improvements to the facility's surveillance activities, as well as intervention and follow-up measures.

Editor's note: Our sources' comments come from a recent audioconference sponsored by The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. HCPro publishes BOIC. To order a tape of the program, "Infection control for long-term care facilities: Key elements for an effective infection control program," call HCPro customer service at 800/650-6787.