- Email: [email protected]
Process surveillance: Auditing infection control policies and procedures
Candace Friedman, M.P.H. Donna Richter, M.S. Thomas Skylis, M.P.H. Don Brown, Ph.D. Ann
Arbor,
Michigan
The infection control team in a university hospital designed, implemented, and evaluated a program to audit infection control policies. Process surveillance techniques of observation and monitoring were used during surveys of patient care areas to evaluate infection control practices. Nineteen unit surveys have been completed in a 2-year period. Analysis of the program has demonstrated it to be an effective method to determine compliance with infection control policies. (AM J INFECT CONTROL 12:228-232, 1984.)
One million of the 30 million patients admitted to U.S. hospitals each year contract nosocomial infections. This represents an infection rate of 3.3%, resulting in 150,000 deaths and an economic loss of approximately 1 billion dollars.‘. 2 The discipline of infection control (IC) emerged to develop programs to identify, prevent, and control nosocomial infections. Infection control programs can analyze infectionrelated problems in an institution and identify procedures and practices that will improve patient care. In 1974 the Center for Disease Control (CDC) identified eight elements necessary for a program to control nosocomial infections: an infection control committee, surveillance activities, isolation procedures, employee health guidelines, patient care activities, microbiology services, continuing education, and environmental control :5 Surveillance was thrust into the forefront of IC in 1976 when the Joint Commission on Accreditation of Hospitals strongly recommended From the Department of Environmental versity Hospitals, Ann Arbor. Reprint requests: Candace Nl5D06-300 N. Ingalls, Ann
228
Health
and
Friedman, University Arbor, Ml 48109.
Safety,
Uni-
Hospitals,
that every hospital designate a person to collect data on nosocomial infections. Surveillance has since been practiced as the continuous collection of data to be used ta identify specific nosocomial problems. After reviewing such data, the infection control committee determines a course of action to control the problems. Today, by dividing surveillance into outcome (data collection) and process (evaluation of practice) categories, surveillance itself constitutes the “control” in an IC program.4 Following is a description of the application and benefits of process surveillance at this institution over a 2-year period.
The University of Michigan Medical Center is a 964-bed university teaching institution located in Ann Arbor. It is one of the largest university-owned hospital systems in the United States and serves as a referral hospital for a region that includes portions of three midwestern states. All major medical services are represented, as are various modes of specialized care. These include hemodialysis, nuclear medicine, oncology, organ transplantation, pediatrics, burn and cardiac surgery, and perinatal medicine.
Volume
12 Number
August,
1984
4
Process surveillance
Fig. lg.
1 Fig. 1A. Front page of Patient Information
Form.
Back page of Patient
OF IC EFFORTS
The IC program has six integrated facets: outcome surveillance, epidemiologic investigation, consultation, education, process surveillance, and research. The CDC states that the optimal control of nosocomial infections depends on surveillance techniques that are capable of identifying the number and characteristics of infections at the time they OCCLK.~ This element, called outcome surveillance, involves collection of data to determine how many patients have a nosocomial infection. Data are then analyzed to indicate endemic rates of infection and to identify increases in specific nosocomial infections. In this institution, outcome surveillance is the primary responsibility of one member of the IC team who is designated the surveillance officer. Outcome surveillance actually measures the end result of IC, the infection rate, and provides only indirect evidence of policy implementation. However, process surveillance can be used to observe, describe, and measure implemen-
Form.
tation of IC policies.4 Our method of process surveillance is called a “unit survey.” Unit surveys are conducted by an IC team consisting of three persons with backgrounds in epidemiology, microbiology, patient care practices, and environmental sanitation. DESCRIPTION
ORQANiZATlON
Information
229
OF UNIT SURVEY
Units to be surveyed are determined according to infection risk identified through outcome surveillance and/or other studies that have emphasized an increased risk to patients. High risk for nosocomial infection has been demonstrated in burn units, medical, surgical and respiratory intensive care units, nurseries, and hemodialysis units. After an area is selected for survey, the team enters the unit unannounced. At that point the charge nurse or head nurse is made aware of the survey purpose and needs. Information and observations are noted on standardized forms. Two data forms are used, one for patient information and the other for interview and environment information. The Patient Information Form (Fig. 1) is completed on each patient in the unit. Data are collected on clinical practice, including intravascular therapy, urinary catheterization, surgical wound care, and respiratory therapy; housekeeping; isolation/precautions practice; and the use of medications and solutions.
American
230
Friedman
et al.
Journal
INFECTION
of
CONTROL
INFECTION COMTROL SURVEY -SUMMARY
Clinical lnformatian Art/Swan Liner
IV Therapy Number peripheralPP
Number arterial ---
Number central ____c__-
Number Swan.
--..-_I-
Number site infectionP
Number with transducer--.---
.--
--
..-.-.
Number with bacteremla---
Number wth bactwemia.-m~mm_.-_.
Bag A c, 24 hr (No. -%I
Sag Aq 24 hr (No. -%)__
Dressing Aq 48 hr (No. -%I--
Drewng At, 48 hr (No. -%I____-
Comments.
Comments--.-.
-----
-____-__
Wounds
Urinary Catheters
Number wrg,cal--
Number folev Number condom
---
Number straghtNumber suprapubic-
___-...
.~
Number with UTI Good maintenance (No. -%I -
Comments
Fig.
2. Interview
and Environment
Form
The Interview and Environment Form (Fig. 2) is used to collect information through questioning appropriate individuals regarding unit policies and practice. It is also used to document observations on environmental conditions. Through the use of the data collection tools, patient care practices can be observed, unit policies can be determined, and the environment can be monitored. Education of personnel on IC practice also occurs during the interview process. Unit survey data are analyzed and compiled into a summary format. The Summary Form (Fig. 3) is divided into two parts. The first outlines information collected so that a review will identify any potential problem areas. Space is also available for necessary comments. The second part of the form gives a qualitative summary of the administrative areas reviewed: patient care, respiratory therapy, pharmacy, housekeeping, and operations management. The quality of overall adherence to IC practices is assessed by the IC team and subjectively ranked in a range between exemplary and unacceptable.
Fig.
3A. Front page of Summary
Form
A narrative report of recommendations is attached to the Summary Form. Noted are IC practices that need to be modified by the area. In addition, specific hospital policies and regulatory compliance or accreditation standards not being followed are referenced. Summary reports are distributed to appropriate persons for the area. This typically involves the hospital administrator, director of nursing, head nurse, medical director, and any other department heads affected by the recommendations. Once the report has been sent, contact is made with the head nurse to discuss the survey results and determine any problem areas or assistance necessary. This may involve the initiation of inservice education programs or special studies. Nineteen unit surveys have been completed in a 2-year period. Ten were in intensive care units and a few required follow-up surveys to
Volume
12 Number
August,
1984
4
Process surveillance
OUTCOME SURVEILLANCE
-
231
EPIDEMIOLOGIC INVESTIGATION
PROCESSSURVElLl.ANCE
CONSULTATION (Policy & Procedures)
Fig. 4. Diagram
RESEARCH
of process
EDUCATION
surveillance
system.
DISCUSSION
‘Range 3s:exemplary good adsquate~poor~ ““*Ccwtable
Fig.
38.
Back page of Summary
Form.
check for compliance. The following are a few of the general problems that were identified and corrected: 1. Noncompliance with the institutional multiple-dose medication policy resulted from lack of knowledge regarding this policy. Distribution of the policy has lead to improvement in compliance. 2. Procedures were performed without necessary equipment or solutions. This has been corrected through purchase of necessary items. 3. Inappropriate attention was given to aseptic technique. Special in-service and informal training has reemphasized the importance of aseptic practices. 4. Storage, equipment processing, and traffic flow problems have been corrected or reorganized to use space and equipment more efficiently.
The objective of the CDC’s Study on the Efficacy of Nosocomial Infection Control (SENIC) project, begun in 1974, was to determine whether and to what degree infection surveillance and control programs are effective in reducing nosocomial infections. The study carried out a detailed analysis of data to evaluate specific components of infection surveillance and control activities such as surveillance techniques, patient care policies, environmental monitoring, and roles of IC personnel.6 Results of this study, which have been reported, note that both surveillance and control measures are necessary to decrease infection rates. The main elements of an IC program are stated as (1) epidemiologic surveillance for occurrence of infections in patients, (2) formulation of policies and procedures to control infections, and (3) an IC practitioner to collect data and coordinate intervention activities. The integration of all these elements necessary for a total, effective IC program can be met by utilizing process surveillance techniques (Fig. 4). Thus process surveillance fills the gap between policy and practice. Findings from unit surveys have resulted in various improvements, including: 1. Adaptation of the institutional isolation/ precautions policy to reflect differences in areas, such as ambulatory care and psychiatric settings 2. Modification of IC guidelines related to short-term intravenous catheterization in areas such as ambulatory care and radiology 3. Development of institutional policies for endoscopic procedures and the use of dis-
American
232
Friedman
et al.
posable equipment because of practices discovered during surveys 4. Increased IC input into product evaluation because of unit problems with new products 5. Closer involvement with the nursing research and quality assurance staff to aid in the development of projects to improve patient care techniques 6. Expanded educational efforts resulting from increased interaction with unit educational coordinators The areas of consultation, research, and education practiced by IC staff have thus been strengthened by information obtained through process surveillance. BUME(YlARV
The unit survey has been well received in this institution. Both administrative and clinical staff receive information regarding the level of compliance with IC policy. The unit survey incorporates the concept of process surveillance through observation, evaluation of practice, monitoring of equipment, and education. In addition to providing an ongoing system for reviewing and verifying the implementation of IC policies,4 process surveillance also allows
INFECTION
Journal
of
CONTROL.
the IC team to make determinations regarding special studies that may need to be done, changes in policy that are necessary, or major educational efforts needed to reinforce specific practice. Axnick* noted that the scope of the IC practitioner’s activities must change from a traditional task orientation to facilitation of a problem-solving process. This goal may be accomplished through process surveillance. Refemnces 1. Centers
for Disease Control: National nosocomial infections study report, annual summary 1979, Atlanta, 1982, Centers for Disease Control. Bennett JV: Human infection: Economic implication and prevention. Ann Intern Med 89:761-763, 1978. Mallison GF: A hospital program for control of nosocomial infections. APIC Newsletter 2: 1-6, 1974. Bryan CS, Deever E: Implementing control measures. AM J INFECT CONTROL 9:101-106, 1981. Centers for Disease Control: Outline for surveillance and control of nosocomial infections, Atlanta, 1972, Centers for Disease Control. 6. Phillips DF: Growing pains: Infection control practice shifts to encompass variety of disciplines. Hospitals 57(3):80-85, 1983. 7. SENIC finds that hospitals’ IC programs reduce infections. Hosp Infect Control 9:149-154, 1982. a. Axnick KJ: Infection control: The next 10 years. Am J Med 70:979-986, 1981.
The American Journal of Infection Control offers a classified advertising section in each issue. It lists positions available and positions desired. Ratea for announcements of 30 words or less are $so.Orl for one insartlon and $48.00 for three or more insertions. Each addttional word is $1.20 and $1.05, respectively. There is a $s.oO charge for box service for the first insertion only. Payment must accompany insertion orders. Send classified ads to the Journal Advertising Department, American Journal of Infection Control, The C. V. Mosby Company, 11330 Westline Industrial Drive, St. Louis MCJ 83146.
Arbor,
Michigan
The infection control team in a university hospital designed, implemented, and evaluated a program to audit infection control policies. Process surveillance techniques of observation and monitoring were used during surveys of patient care areas to evaluate infection control practices. Nineteen unit surveys have been completed in a 2-year period. Analysis of the program has demonstrated it to be an effective method to determine compliance with infection control policies. (AM J INFECT CONTROL 12:228-232, 1984.)
One million of the 30 million patients admitted to U.S. hospitals each year contract nosocomial infections. This represents an infection rate of 3.3%, resulting in 150,000 deaths and an economic loss of approximately 1 billion dollars.‘. 2 The discipline of infection control (IC) emerged to develop programs to identify, prevent, and control nosocomial infections. Infection control programs can analyze infectionrelated problems in an institution and identify procedures and practices that will improve patient care. In 1974 the Center for Disease Control (CDC) identified eight elements necessary for a program to control nosocomial infections: an infection control committee, surveillance activities, isolation procedures, employee health guidelines, patient care activities, microbiology services, continuing education, and environmental control :5 Surveillance was thrust into the forefront of IC in 1976 when the Joint Commission on Accreditation of Hospitals strongly recommended From the Department of Environmental versity Hospitals, Ann Arbor. Reprint requests: Candace Nl5D06-300 N. Ingalls, Ann
228
Health
and
Friedman, University Arbor, Ml 48109.
Safety,
Uni-
Hospitals,
that every hospital designate a person to collect data on nosocomial infections. Surveillance has since been practiced as the continuous collection of data to be used ta identify specific nosocomial problems. After reviewing such data, the infection control committee determines a course of action to control the problems. Today, by dividing surveillance into outcome (data collection) and process (evaluation of practice) categories, surveillance itself constitutes the “control” in an IC program.4 Following is a description of the application and benefits of process surveillance at this institution over a 2-year period.
The University of Michigan Medical Center is a 964-bed university teaching institution located in Ann Arbor. It is one of the largest university-owned hospital systems in the United States and serves as a referral hospital for a region that includes portions of three midwestern states. All major medical services are represented, as are various modes of specialized care. These include hemodialysis, nuclear medicine, oncology, organ transplantation, pediatrics, burn and cardiac surgery, and perinatal medicine.
Volume
12 Number
August,
1984
4
Process surveillance
Fig. lg.
1 Fig. 1A. Front page of Patient Information
Form.
Back page of Patient
OF IC EFFORTS
The IC program has six integrated facets: outcome surveillance, epidemiologic investigation, consultation, education, process surveillance, and research. The CDC states that the optimal control of nosocomial infections depends on surveillance techniques that are capable of identifying the number and characteristics of infections at the time they OCCLK.~ This element, called outcome surveillance, involves collection of data to determine how many patients have a nosocomial infection. Data are then analyzed to indicate endemic rates of infection and to identify increases in specific nosocomial infections. In this institution, outcome surveillance is the primary responsibility of one member of the IC team who is designated the surveillance officer. Outcome surveillance actually measures the end result of IC, the infection rate, and provides only indirect evidence of policy implementation. However, process surveillance can be used to observe, describe, and measure implemen-
Form.
tation of IC policies.4 Our method of process surveillance is called a “unit survey.” Unit surveys are conducted by an IC team consisting of three persons with backgrounds in epidemiology, microbiology, patient care practices, and environmental sanitation. DESCRIPTION
ORQANiZATlON
Information
229
OF UNIT SURVEY
Units to be surveyed are determined according to infection risk identified through outcome surveillance and/or other studies that have emphasized an increased risk to patients. High risk for nosocomial infection has been demonstrated in burn units, medical, surgical and respiratory intensive care units, nurseries, and hemodialysis units. After an area is selected for survey, the team enters the unit unannounced. At that point the charge nurse or head nurse is made aware of the survey purpose and needs. Information and observations are noted on standardized forms. Two data forms are used, one for patient information and the other for interview and environment information. The Patient Information Form (Fig. 1) is completed on each patient in the unit. Data are collected on clinical practice, including intravascular therapy, urinary catheterization, surgical wound care, and respiratory therapy; housekeeping; isolation/precautions practice; and the use of medications and solutions.
American
230
Friedman
et al.
Journal
INFECTION
of
CONTROL
INFECTION COMTROL SURVEY -SUMMARY
Clinical lnformatian Art/Swan Liner
IV Therapy Number peripheralPP
Number arterial ---
Number central ____c__-
Number Swan.
--..-_I-
Number site infectionP
Number with transducer--.---
.--
--
..-.-.
Number with bacteremla---
Number wth bactwemia.-m~mm_.-_.
Bag A c, 24 hr (No. -%I
Sag Aq 24 hr (No. -%)__
Dressing Aq 48 hr (No. -%I--
Drewng At, 48 hr (No. -%I____-
Comments.
Comments--.-.
-----
-____-__
Wounds
Urinary Catheters
Number wrg,cal--
Number folev Number condom
---
Number straghtNumber suprapubic-
___-...
.~
Number with UTI Good maintenance (No. -%I -
Comments
Fig.
2. Interview
and Environment
Form
The Interview and Environment Form (Fig. 2) is used to collect information through questioning appropriate individuals regarding unit policies and practice. It is also used to document observations on environmental conditions. Through the use of the data collection tools, patient care practices can be observed, unit policies can be determined, and the environment can be monitored. Education of personnel on IC practice also occurs during the interview process. Unit survey data are analyzed and compiled into a summary format. The Summary Form (Fig. 3) is divided into two parts. The first outlines information collected so that a review will identify any potential problem areas. Space is also available for necessary comments. The second part of the form gives a qualitative summary of the administrative areas reviewed: patient care, respiratory therapy, pharmacy, housekeeping, and operations management. The quality of overall adherence to IC practices is assessed by the IC team and subjectively ranked in a range between exemplary and unacceptable.
Fig.
3A. Front page of Summary
Form
A narrative report of recommendations is attached to the Summary Form. Noted are IC practices that need to be modified by the area. In addition, specific hospital policies and regulatory compliance or accreditation standards not being followed are referenced. Summary reports are distributed to appropriate persons for the area. This typically involves the hospital administrator, director of nursing, head nurse, medical director, and any other department heads affected by the recommendations. Once the report has been sent, contact is made with the head nurse to discuss the survey results and determine any problem areas or assistance necessary. This may involve the initiation of inservice education programs or special studies. Nineteen unit surveys have been completed in a 2-year period. Ten were in intensive care units and a few required follow-up surveys to
Volume
12 Number
August,
1984
4
Process surveillance
OUTCOME SURVEILLANCE
-
231
EPIDEMIOLOGIC INVESTIGATION
PROCESSSURVElLl.ANCE
CONSULTATION (Policy & Procedures)
Fig. 4. Diagram
RESEARCH
of process
EDUCATION
surveillance
system.
DISCUSSION
‘Range 3s:exemplary good adsquate~poor~ ““*Ccwtable
Fig.
38.
Back page of Summary
Form.
check for compliance. The following are a few of the general problems that were identified and corrected: 1. Noncompliance with the institutional multiple-dose medication policy resulted from lack of knowledge regarding this policy. Distribution of the policy has lead to improvement in compliance. 2. Procedures were performed without necessary equipment or solutions. This has been corrected through purchase of necessary items. 3. Inappropriate attention was given to aseptic technique. Special in-service and informal training has reemphasized the importance of aseptic practices. 4. Storage, equipment processing, and traffic flow problems have been corrected or reorganized to use space and equipment more efficiently.
The objective of the CDC’s Study on the Efficacy of Nosocomial Infection Control (SENIC) project, begun in 1974, was to determine whether and to what degree infection surveillance and control programs are effective in reducing nosocomial infections. The study carried out a detailed analysis of data to evaluate specific components of infection surveillance and control activities such as surveillance techniques, patient care policies, environmental monitoring, and roles of IC personnel.6 Results of this study, which have been reported, note that both surveillance and control measures are necessary to decrease infection rates. The main elements of an IC program are stated as (1) epidemiologic surveillance for occurrence of infections in patients, (2) formulation of policies and procedures to control infections, and (3) an IC practitioner to collect data and coordinate intervention activities. The integration of all these elements necessary for a total, effective IC program can be met by utilizing process surveillance techniques (Fig. 4). Thus process surveillance fills the gap between policy and practice. Findings from unit surveys have resulted in various improvements, including: 1. Adaptation of the institutional isolation/ precautions policy to reflect differences in areas, such as ambulatory care and psychiatric settings 2. Modification of IC guidelines related to short-term intravenous catheterization in areas such as ambulatory care and radiology 3. Development of institutional policies for endoscopic procedures and the use of dis-
American
232
Friedman
et al.
posable equipment because of practices discovered during surveys 4. Increased IC input into product evaluation because of unit problems with new products 5. Closer involvement with the nursing research and quality assurance staff to aid in the development of projects to improve patient care techniques 6. Expanded educational efforts resulting from increased interaction with unit educational coordinators The areas of consultation, research, and education practiced by IC staff have thus been strengthened by information obtained through process surveillance. BUME(YlARV
The unit survey has been well received in this institution. Both administrative and clinical staff receive information regarding the level of compliance with IC policy. The unit survey incorporates the concept of process surveillance through observation, evaluation of practice, monitoring of equipment, and education. In addition to providing an ongoing system for reviewing and verifying the implementation of IC policies,4 process surveillance also allows
INFECTION
Journal
of
CONTROL.
the IC team to make determinations regarding special studies that may need to be done, changes in policy that are necessary, or major educational efforts needed to reinforce specific practice. Axnick* noted that the scope of the IC practitioner’s activities must change from a traditional task orientation to facilitation of a problem-solving process. This goal may be accomplished through process surveillance. Refemnces 1. Centers
for Disease Control: National nosocomial infections study report, annual summary 1979, Atlanta, 1982, Centers for Disease Control. Bennett JV: Human infection: Economic implication and prevention. Ann Intern Med 89:761-763, 1978. Mallison GF: A hospital program for control of nosocomial infections. APIC Newsletter 2: 1-6, 1974. Bryan CS, Deever E: Implementing control measures. AM J INFECT CONTROL 9:101-106, 1981. Centers for Disease Control: Outline for surveillance and control of nosocomial infections, Atlanta, 1972, Centers for Disease Control. 6. Phillips DF: Growing pains: Infection control practice shifts to encompass variety of disciplines. Hospitals 57(3):80-85, 1983. 7. SENIC finds that hospitals’ IC programs reduce infections. Hosp Infect Control 9:149-154, 1982. a. Axnick KJ: Infection control: The next 10 years. Am J Med 70:979-986, 1981.
The American Journal of Infection Control offers a classified advertising section in each issue. It lists positions available and positions desired. Ratea for announcements of 30 words or less are $so.Orl for one insartlon and $48.00 for three or more insertions. Each addttional word is $1.20 and $1.05, respectively. There is a $s.oO charge for box service for the first insertion only. Payment must accompany insertion orders. Send classified ads to the Journal Advertising Department, American Journal of Infection Control, The C. V. Mosby Company, 11330 Westline Industrial Drive, St. Louis MCJ 83146.