Surveillance is crucial to LTC infection control

Accreditation Connection, March 15, 2004

IC activities performed in long-term care (LTC) facilities differ from those in hospitals, but both need constant and effective surveillance.

"We need an ongoing program for surveillance and a systematic approach to interpreting data," said Gail Bennett, RN, MSN, CIC, executive director of ICP Associates, a consulting firm in Rome, GA. It provides them with "baseline data, [which] helps us know whether we've had an impact on IC."

Perform surveillance activities to

  • establish baseline endemic health care-associated infection (HAI) rates

  • facilitate early awareness of epidemics or clusters of health care-associated infections

  • identify problems for actions that may decrease rates and lead to prevention of future infections

    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.

    Types of surveillance

    These surveillance activities come in two varieties:

  • Traditional, total house surveillance-This involves finding all HAIs all the time, said Bennett. It's useful for establishing endemic infection rates, but is also time consuming due to the wide scope of infections you must track.

  • Targeted surveillance-Facilities may target geographic locations or types of HAIs for review, Bennett noted. Consider high-risk, high-volume, or problem-prone procedures.

    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.

    Methods of finding infections/data sources

    There are several methods of finding infections in your facility:

  • Microbiology reports-IC professionals should have access to them prior to filing a medical record.

  • Unit-generated report forms.

  • 24-hour reports.

  • Antibiotic monitoring.

  • Unit rounds/communication forms/verbal reports.

  • Medical record review.

  • Concurrent reviews, not retrospective-do surveillance several times a week, suggests Bennett. If you do it after a month, it's less accurate.

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

    Definitions of infection

    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

    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:

  • All symptoms must be new or acutely worse. Many residents have chronic symptoms, such as cough or urinary urgency, that are not associated with infection. However, a change in the resident's status is an important indication that an infection may be developing.

  • Noninfectious causes of signs and symptoms should always be considered before a diagnosis of infection is made.

  • Identification of infection should not be based on a single piece of evidence. Microbiologic and radiologic findings should be used only to confirm clinical evidence of infection. Similarly, physician diagnosis should be accompanied by compatible signs and symptoms of infection.

    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.

    Data interpretation

    When examining infection data, look for the following:

  • Clusters of infections, or closely grouped series of infections

  • Outbreaks, or a collection of more cases than normal

  • Sentinel events, which are single occurrences that require action

  • Trends, or an increase in specific infections over time

  • Seasonal occurrences, such as the increase of influenza and upper or lower respiratory problems in the winter

    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.

    Calculating infection rates

    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.


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