3. DATA PROCESSING
Data are collected ,
analyzed, and
transformed into
useful information
12/31/2013
٣
4. Presentation Outline
CDC
Criteria of HAIs
Type & Methodology of Surveillance
work
Design an interpretive surveillance
report
Data display
Benchmarking
Benchmarking requirements and
problems
12/31/2013
٤
5. What is Surveillance?
The ongoing, system collection,
analysis, and interpretation of
health data essential to the
planning, implementation, and
evaluation of public health
practice, closely integrated with
timely dissemination of these
data to those who need to know.
12/31/2013
٥
7. Purposes of Surveillance-1
1. Reducing the infection rate
within a hospital.
2. Establishing endemic (baseline)
rates.
3. Identifying outbreaks.
12/31/2013
٧
8. Purposes of Surveillance-2
4. Convincing medical staff.
5. Defending malpractice claims.
6. Comparing infection rates
among hospitals.
12/31/2013
٨
9. Steps in Surveillance
Definition of the event(s).
Systematic collection of data.
Preparation of Surveillance Report
Analysis & interpretation.
Benchmarking.
Consuming the results for
improvement.
12/31/2013
٩
12. Device-Associated Infection
There is no minimum period of time that the device
must be in place for the infection to be considered
device-associated.
The date of the device-associated HAI event is
either the date on which the first clinical evidence
appeared or the date on which the specimen used
to meet the HAI criteria was collected, whichever
came first.
If the device-associated HAI develops within 48
hours of discharge from a location, then the HAI is
associated with the discharging location.
12/31/2013
١٢
13. Central Line-Associated Bloodstream Infection
(CLABSI) Event
A CLABSI is a primary bloodstream infection
(BSI) in a patient who had a central line or
umbilical catheter in place at the time of or
within 48 hours before onset of the BSI.
Use
12/31/2013
CDC Criteria for Identification
١٣
14. Ventilator-Associated Pneumonia (VAP)
Event:
A VAP is pneumonia (PNEU) that is
identified using a combination of
radiologic, clinical and laboratory criteria
and occurs in a patient who was intubated
and ventilated at the time of or within 48
hours before the onset of pneumonia.
Use
12/31/2013
CDC Criteria for Identification
١٤
15. Catheter-Associated Urinary Tract Infection
(CAUTI) Event:
CAUTI is defined as a symptomatic urinary
tract infection (SUTI) or asymptomatic
bacteremic UTI (ABUTI) in a patient who
had an indwelling urinary catheter at the
time of or within 48 hours before onset of
the event.
Use
12/31/2013
CDC Criteria for Identification
١٥
16. Dialysis Event (DE)
Hospitalization
In-unit IV
antimicrobial starts
Positive blood
culture
12/31/2013
All hospitalizations that involved an
overnight stay in a hospital and is
not limited to infections or
situations
All IV antimicrobial starts and is not
limited to those with vancomycin or
for a vascular access problem
All patients with a positive blood
culture even if they did not have an
associated hospitalization or in-unit
IV antimicrobial start
١٦
17. PROCEDURE-ASSOCIATED
MODULE
Surgical Site Infection (SSI) Event:
The SSI is an infection that occurs within 30 days
(or within one year for an implant in the case of
organ/space SSI) after an operative procedure that
involves the skin or subcutaneous tissue
(superficial incisional SSI), deep soft tissue (deep
incisional SSI), or any other part of the body that is
opened or manipulated during the operative
procedure (organ/space SSI).
Use CDC Criteria for Identification
12/31/2013
١٧
18. Post-Procedure Pneumonia (PPP)
Event:
PPE is a pneumonia that is identified
using a combination of radiological,
clinical and laboratory criteria (such
as VAP) and occurs after an inpatient
operation but prior to discharge.
12/31/2013
١٨
19. Location/Period of
Surveillance Events
CLABSI: Surveillance for CLABSI in at least one location
(ICU, NICU, SCA, others) in the healthcare institution for at
least one calendar month.
VAP: Surveillance for VAP in at least one location (ICU,
NICU, SCA, others) in the healthcare institution for at least
one calendar month
CAUTI: Surveillance for CAUTI performed in at least one
location (ICU, SCA, others) in the healthcare institution for at
least one calendar month
DE: Surveillance for DE for at least 6 months among chronic
hemodialysis patients at an outpatient hemodialysis facility
SSI: Surveillance for at least one NHSN operative procedure
performed in surgical patients in any inpatient/outpatient
setting for at least one month
PPP: Surveillance for at least one NHSN operative
procedure performed only in a surgical inpatient setting for
at least one month
12/31/2013
١٩
20. SURVEILLANCE METHODOLOGY
The Patient Safety surveillance modules
Active
Patient-based
Prospective,
Priority-directed surveillance
Of device/medication/procedure-associated
infection events
Their corresponding denominator data by a
trained infection control professional (ICP).
12/31/2013
٢٠
21. SURVEILLANCE METHODOLOGY
Active surveillance
a) Trained personnel, mainly ICPs, are vigorously
look for HAIs
b) Information is accumulated using a variety of data
sources within and beyond the nursing ward
Passive surveillance
a) Persons who do not have a primary surveillance
role, such as ward nurses or respiratory therapists,
identify and report HAIs
12/31/2013
٢١
22. Patient-based and laboratory-based
surveillance
1. Patient-based surveillance
a) Count HAIs, assess risk factors, and monitor patient
care procedures and practices for adherence to
infection control principles
b) Requires ward rounds and discussion with
caregivers
2. Laboratory-based surveillance
a) Detection is based solely on the findings of
laboratory studies of clinical Specimens.
12/31/2013
٢٢
23. Prospective and Retrospective
Surveillance
1. Prospective surveillance
a) Monitor patients during their
hospitalization
b) For SSIs, also monitor during the
post-discharge period
2. Retrospective surveillance
a) Identify infections via chart reviews
after patient discharge
12/31/2013
٢٣
24. Priority-directed and
comprehensive surveillance
1. Priority-directed surveillance
(Targeted or focused surveillance)
a) Objectives for surveillance are defined
b) The focus is on specific events, processes,
organisms, and/or patient populations
2. Comprehensive surveillance
Universal Surveillance
a) Continuous monitoring of all patients for all events
and/or processes
12/31/2013
٢٤
26. Surveillance Collection Forms
MC 2 7 0 5 (R e v . 0 6 /0 4 )
V a n d e r b i l t U n i v e rs ity M e d ic a l C en te r
M o n ro e C a re ll J r.
OR
at V an d e r b il t
N u r s i n g C h e c k l i s t:
C e n tr a l V e n o u s C a t h e te r I n s e r ti o n
N O T E : P le a s e u s e e i th e r b l a c k o r b l u e i n k to c o m p l e te th i s f o rm .
CCU
B I CU
M R #:
T im e s t ar t
( 1 s t n e e d le s ti c k ) :
In s e r t io n S it e :
In t e r n a l J u g u l a r
S ub c lav ia n
F em or a l
O th e r ( s p e c i fy ) :
S id e :
Rig ht
L e ft
L is t a ll s it e s w h e r e in s e r t io n w a s a t te m p t e d .
R IJ
L IJ
RS C
L SC
M IC U
PCCU
/
:
D a te :
T y p e o f c a th e t e r :
D ou ble lum e n
Tr i p le lu m e n
In t ro d u c e r
S w a n- G a n z
V a s c a th
TI C U
NI C U
RF
N SI C U
O th e r
S I CU
P le a s e u s e m il i ta ry ti m e
(i .e . 1 :0 0 p m i s 1 3 :0 0 )
/
T im e en d
( c a th e te r s e c u r e d ) :
In d ic a t io n s fo r u s e :
P r es s or s
H e m o d y n a m i c m o n i t.
F l u i d s /b l o o d p r o d u c ts
F r e q u e n t la b d r a w s
LF
:
C h e c k if :
C o n s e n t o b ta i n e d
P t /F a m i l y t e a c h i n g d o n e
G uid ew ir e e x c h an ge
O th e r ( s p e c i fy ) :
T h e p r o v id e r in s e r t in g t h is lin e :
a . H a n d e d - o f f h is /h e r pa g e r b e fo r e th e p r o c e d u r e ?
Yes
No
D id n’t as k
b . W a s h e d h a n d s im m e d ia te ly p r io r to p r o c e d u r e ?
Yes
No
D id n’t as k
c . H a s p r e v io u s ly p la c e d a t le a s t f iv e ( 5 ) c e n t r a l lin e s ?
Yes
No *
D id n’t as k
* If “ N o ” , w a s th is p r o c e d u r e s u p e rv is e d b y s om e on e w ith le a s t f iv e ( 5 ) c e n t r a l lin e s e x p e r ie n c e ?
Ye s
No
Did n’t a s k
B a r r ie r p r e c a u t io n s ( c h e c k a n y u s e d ) :
S t er ile glov es
S te r il e g o w n
Ma sk
S te r i le to w e l s
F ull bo dy dr a pe
D e s c r ib e th e le v e l o f t r a in in g o f t he p e r s o n w h o a c t u a ll y in s e r t e d t h e lin e ?
M e d i c a l S tu d e n t
In te r n ( P G Y -1 )
R e s i d e n t (P G Y - 2 + )
F ellow
A tte n d i n g
N u r s e P ra c ti ti o n e r
H o w m a n y d if f e r e n t ne e d le s t ic k s d id t h e p a tie n t r e c e iv e ( n u m b e r o f s k in b r e a k s ) ?
1
2
3
4
5
6+
U n k no w n
W a s t h e s t e r ile f ie ld m a in t a in e d t h r o u g h ou t th e e n t ir e p r o c e d u r e ?
Yes
P r e - in s e r tio n s k in p r e p (c h e c k a n y u s e d ) :
A lc o ho l
B e ta d i n e (p o v i d o n e -i o d i n e )
O th e r ( s p e c i fy ) :
C h lo r h e x i d i n e
D e s c r ib e th e c ir c u m s t a n c e s u n de r w h ic h t h is lin e w a s p la c e d :
No n- e m e r ge nt
E m e r g e n t ( l i fe - th r e a te n i n g o r c o d e s i t u a ti o n )
F o llo w - u p C X R :
O r d e re d
C X R f in d in g s (c h e c k a ll t h a t a p p ly ) :
N o p n e u m o th o r a x
C a t h e te r i n g o o d p o s i t io n
P n e u m o t h o r a x (d e s c r i b e a c ti o n t a k e n ):
C a th e te r p o s i ti o n a d ju s te d ( d e s c r i b e ) :
T y p e o f d re s s in g :
B io - oc c lus iv e
D r e s s in g a p p lie d b y :
Nu r s e
G a uz e
O th e r ( s p e c i fy ) :
P r o c e d u r a li s t
P a t ie n t to le r a t e d t he p r oc e d u r e w e ll?
C o m p lic a tio n s ?
No ne
No
P r e -e x i s ti n g i n fe c ti o n
N o t o r d e r e d ( s p e c i fy r e a s o n ):
O th e r ( s p e c i fy ) :
Ye s
No
C o m m e n ts :
P l a c e m e n t u n s u c c e s s fu l
O th e r ( d e s c ri b e ) :
P l e a s e f ile p a g e 2 in p a t ie n t s c h a r t a n d r e t u r n t o p f o r m t o t h e de s ig n a te d lo c a t io n i n th e IC U .
S ig n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D a t e : _ _ __ __ _ __ __ _ __ __ _
MC 2 7 0 5 (R e v . 0 6 /0 4 )
Va n d e r b i l t U n i v e rs ity M e d ic a l C en te r
M o n ro e C a rell J r.
OR
at V an d e r b il t
N u r s i n g C h e c k l i s t:
C e n tr a l V e n o u s C a t he te r I n s e r ti o n
NO T E : P le a s e u s e eith er blac k o r blue in k to c om ple te th is f o rm .
CCU
B I CU
M R #:
T im e s t ar t
( 1 s t ne ed le s tic k ) :
In se rt io n S it e :
S id e :
Int er na l J ugu lar
Rig ht
S ub c lav ia n
Le ft
F em or a l
O th er ( s pe c ify ) :
L ist all sit e s w h e re in s e rt io n w a s a t te m p t e d .
R IJ
L IJ
RS C
L SC
M IC U
PCCU
/
:
D a te :
T yp e o f c a th e t er :
D ou ble lum e n
Tr ip le lu m e n
Int ro d uc e r
S w a n- G a n z
V as c a th
TI C U
NI C U
N SI C U
O the r
S I CU
P le a s e u s e m il i ta ry ti m e
(i .e . 1 :0 0 p m i s 1 3 :0 0 )
/
T im e en d
( c a th ete r s ec ur e d) :
In d ic at io n s fo r u se :
C h e ck if :
P r es s or s
C on s e nt o bta ine d
H e m o dy na m ic m o nit.
P t /F a m ily t e ac h ing do ne
F luid s /b lo od pr o du c ts
G uid ew ir e e x c h an ge
F r e qu en t la b dr aw s
RF
:
LF
O th er ( s pe c ify ) :
T h e p ro v id e r in s e rt in g t h is lin e :
a. H a n d ed - o f f h is /h e r pa g e r b e fo r e th e p ro c e d u re ?
Yes
No
D id n’t as k
b . W a s h ed h an d s im m e d ia te ly p rio r to p ro c ed u re ?
Yes
No
D id n’t as k
c. H a s p rev io u s ly p la c ed a t le a st f iv e ( 5) c en t ra l lin e s ?
Yes
No *
D id n’t as k
* If “ No ” , w as th is p ro c ed u re s u p e rv is e d b y s om e on e w ith le as t f iv e ( 5) c en t ra l lin e s e x p erie n c e?
Ye s
No
Did n’t a s k
Ba rr ier p re c au t io n s ( ch e c k a n y u se d ) :
S t er ile glov es
S te r ile g ow n
Ma sk
S te r ile tow e ls
F ull bo dy dr a pe
De s c rib e th e lev e l o f t ra in in g o f t he p ers o n w h o a ct u a ll y in se rt e d t h e lin e ?
M e dic al S tu de nt
In te r n ( P G Y -1 )
Re s ide nt (P G Y - 2+ )
F ellow
A tte nd in g
N u r s e P ra c titio ne r
Ho w m a n y d if f er en t ne e d le st ic k s d id t h e p a tie n t r ec eiv e ( n u m b e r o f s kin b re ak s ) ?
1
2
3
4
5
6+
U n k no w n
W a s t h e st e rile f ie ld m ain t a in e d t h ro u g h ou t th e e n t ire p ro c ed u re?
Yes
P re - in s er tio n s kin p re p (c h e ck a n y u se d ) :
A lc o ho l
B e ta dine (p ov id on e -io din e)
O th er ( s pe c ify ) :
Ch lo r he x id ine
De s c rib e th e c irc u m st an ce s u n de r w h ic h t h is lin e w as p lac e d :
No n- e m e r ge nt
E m e r ge n t ( life - thr e a te ning o r c o de s it ua tion )
F o llo w - u p C X R :
O r de re d
CX R f in d in g s (c h e ck a ll t h a t a p p ly) :
No p ne u m o th or a x
C at he te r in g oo d po s it io n
T yp e o f d re s sin g :
P n eu m ot ho r ax (d es c r ibe a c tio n t a k en ):
C a the te r p os itio n ad ju s te d ( de s c r ibe ) :
B io - oc c lus iv e
G a uz e
O th er ( s pe c ify ) :
Nu r s e
P r o c e dur a lis t
Dr es s in g a p p lie d b y :
P a t ien t to le ra t ed t he p roc e d u re w e ll?
Ye s
Co m p lic a tio n s?
No ne
No
P r e -e x is tin g in fe c tio n
No t or de r e d ( s pe c ify r e as o n ):
O th er ( s pe c ify ) :
No
C o m m e n ts :
P la c e m e nt un s uc c e s s ful
O th er ( d es c rib e) :
P l e as e f ile p ag e 2 in p at ie n t s ch a rt a n d re t u rn t o p f o rm t o t h e de s ig n a te d lo ca t io n i n th e IC U .
S ig n at u re : _ __ __ _ __ __ __ _ __ __ __ _ __ __ __ _ __ __ _ __ __ __ _ __ __ __ _
D a t e : _ _ __ __ _ __ __ _ __ __ _
MC 2 7 0 5 (R e v . 0 6 /0 4 )
V a n d e r b i l t U n i v e rs ity M e d ic a l C en te r
M o n ro e C a re ll J r.
OR
at V an d e r b il t
N u r s i n g C h e c k l i s t:
C e n tr a l V e n o u s C a t h e te r I n s e r ti o n
N O T E : P le a s e u s e e i th e r b l a c k o r b l u e i n k to c o m p l e te th i s f o rm .
CCU
B I CU
M R #:
D a te :
T y p e o f c a th e t e r :
D ou ble lum e n
Tr i p le lu m e n
In t ro d u c e r
S w a n- G a n z
V a s c a th
T im e s t ar t
( 1 s t n e e d le s ti c k ) :
In s e r t io n S it e :
In t e r n a l J u g u l a r
S ub c lav ia n
F em or a l
O th e r ( s p e c i fy ) :
L is t a ll s it e s w h e r e in s e r t io n w a s a t te m p t e d .
R IJ
L IJ
RS C
L SC
S id e :
Rig ht
L e ft
M IC U
PCCU
/
:
TI C U
NI C U
RF
N SI C U
O th e r
S I CU
P le a s e u s e m il i ta ry ti m e
(i .e . 1 :0 0 p m i s 1 3 :0 0 )
/
T im e en d
( c a th e te r s e c u r e d ) :
In d ic a t io n s fo r u s e :
P r es s or s
H e m o d y n a m i c m o n i t.
F l u i d s /b l o o d p r o d u c ts
F r e q u e n t la b d r a w s
LF
:
C h e c k if :
C o n s e n t o b ta i n e d
P t /F a m i l y t e a c h i n g d o n e
G uid ew ir e e x c h an ge
O th e r ( s p e c i fy ) :
T h e p r o v id e r in s e r t in g t h is lin e :
a . H a n d e d - o f f h is /h e r pa g e r b e fo r e th e p r o c e d u r e ?
Yes
No
D id n’t as k
b . W a s h e d h a n d s im m e d ia te ly p r io r to p r o c e d u r e ?
Yes
No
D id n’t as k
c . H a s p r e v io u s ly p la c e d a t le a s t f iv e ( 5 ) c e n t r a l lin e s ?
Yes
No *
D id n’t as k
* If “ N o ” , w a s th is p r o c e d u r e s u p e rv is e d b y s om e on e w ith le a s t f iv e ( 5 ) c e n t r a l lin e s e x p e r ie n c e ?
Ye s
No
Did n’t a s k
B a r r ie r p r e c a u t io n s ( c h e c k a n y u s e d ) :
S t er ile glov es
S te r il e g o w n
Ma sk
S te r i le to w e l s
D e s c r ib e th e le v e l o f t r a in in g o f t he p e r s o n w h o a c t u a ll y in s e r t e d t h e lin e ?
M e d i c a l S tu d e n t
In te r n ( P G Y -1 )
R e s i d e n t (P G Y - 2 + )
F ellow
H o w m a n y d if f e r e n t ne e d le s t ic k s d id t h e p a tie n t r e c e iv e ( n u m b e r o f s k in b r e a k s ) ?
1
2
3
4
5
6+
U n k no w n
W a s t h e s t e r ile f ie ld m a in t a in e d t h r o u g h ou t th e e n t ir e p r o c e d u r e ?
Yes
P r e - in s e r tio n s k in p r e p (c h e c k a n y u s e d ) :
A lc o ho l
B e ta d i n e (p o v i d o n e -i o d i n e )
F ull bo dy dr a pe
A tte n d i n g
N u r s e P ra c ti ti o n e r
O th e r ( s p e c i fy ) :
C h lo r h e x i d i n e
D e s c r ib e th e c ir c u m s t a n c e s u n de r w h ic h t h is lin e w a s p la c e d :
No n- e m e r ge nt
E m e r g e n t ( l i fe - th r e a te n i n g o r c o d e s i t u a ti o n )
F o llo w - u p C X R :
O r d e re d
C X R f in d in g s (c h e c k a ll t h a t a p p ly ) :
N o p n e u m o th o r a x
C a t h e te r i n g o o d p o s i t io n
T y p e o f d re s s in g :
B io - oc c lus iv e
D r e s s in g a p p lie d b y :
Nu r s e
P a t ie n t to le r a t e d t he p r oc e d u r e w e ll?
C o m p lic a tio n s ?
No ne
No
P r e -e x i s ti n g i n fe c ti o n
N o t o r d e r e d ( s p e c i fy r e a s o n ):
P n e u m o t h o r a x (d e s c r i b e a c ti o n t a k e n ):
C a th e te r p o s i ti o n a d ju s te d ( d e s c r i b e ) :
G a uz e
O th e r ( s p e c i fy ) :
P r o c e d u r a li s t
Ye s
P l a c e m e n t u n s u c c e s s fu l
O th e r ( s p e c i fy ) :
No
C o m m e n ts :
O th e r ( d e s c ri b e ) :
P l e a s e f ile p a g e 2 in p a t ie n t s c h a r t a n d r e t u r n t o p f o r m t o t h e de s ig n a te d lo c a t io n i n th e IC U .
S ig n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
12/31/2013
D a t e : _ _ __ __ _ __ __ _ __ __ _
٢٦
27. SURVEILLANCE DATA ANALYSIS
1. Incidence rate:
This rate is a measure of the frequency with which an event
occurs in a population over a defined time period. The numerator
is the number of new cases that occur during the defned time
period, and the denominator is the population at risk.
2.
Prevalence rate:
This rate is the proportion of persons in a population who have a
particular disease or condition (new and previously existing) at a
specified point in time or over a specified period of time.
Note: Attack rate is a type of incidence rate used to measure the frequency
of new cases of a disease or condition in a specifc population during a
given (short) period of time and is expressed as a percentage.
12/31/2013
٢٧
28.
Incidence = new cases x constant (1000)
population at risk
Prevalence = existing cases x constant(1000)
population at risk
12/31/2013
28
29. SURVEILLANCE DATA ANALYSIS
Measures of Frequency:
1. Rate: an expression of the frequency with which an
event occurs in a defined population; for example, the
CLABSI incidence rate is 5.3 per 1,000 CL-days
2. Ratio: the value obtained by dividing one quantity by
another; for example, the ratio of females to males is 2:1
3. Proportion: a type of ratio in which the values in the
numerator are included in(i.e., are a subset of) the
denominator; for example, 33% of the population is in
risk category 1
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31. Population at risk
Patient days / residents days
Device days
central
line days
ventilator days
Foley catheter days
Procedures performed
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31
33. Calculating Rates
CLABSI Infection Rate = No. of HAIs associated with Central Line x 1000
No. of Central Line days
Utilization Ratio of Central Line = No. of days of the Central Line used
Total no. of patient days
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34. Calculating Rates
CAUTI Infection Rate = No. of HAIs associated with Urinary Catheter 1000
No. of urinary catheter days
Utilization Ratio of Urinary Catheter = No. of days of the Urinary Catheter
Total no. of patient days
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35. Calculating Rates
VAP Infection Rate = No. of HAIs associated with ventilator x 1000
No. of ventilator days
Utilization Ratio of Ventilator = No. of days of the catheter used
Total no. of patient days
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36. Calculating Rates
SSI Rate by Type of Operation = No. of SSI in a specific type of operation x 100
Total no. of that operation
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37. Surveillance Report
1.Define the event, population, setting
and time period ( e.g. surgical site
infections in patients undergoing
coronary artery bypass graft in
hospital A from January through
December 2013
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38. Surveillance Report
2. State the criteria used for defining a
case (CDC criteria)
3. Specify the number of cases or
events identified and the number in
population studied (e.g. 2 surgical site
infections in 179 total hip replacement
procedures performed)
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39. Surveillance Report
4. Explain the methodology used to
identify cases (e.g., case reports from
personnel and review of medical
records and laboratory results.
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40. Surveillance Report
5. Identify the statistical methods and
calculations used, when appropriate
(e.g., SSI Rate in April = # patients
with SSI after selected operations in
April/ Total # of selected operations
performed in April x 1000)
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41. Surveillance Report
6. State the purpose for conducting
surveillance ( e.g., to reduce the rate
of occurrence of an event).
7. Interpret the findings in a manner
that is understandable to those who
read the report.
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42. Surveillance Report
8. Describe any actions taken and
recommendations made for
prevention and control measures.
9. Identify the author and date of the
report.
10. Identify the recipients of the report
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43. Design an Interpretive
Surveillance Report
The report should be disseminated to
those managers and healthcare
providers in the organization who can
use the findings to influence
performance improvement activities.
Monthly Surveillance Report
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44. Data Display Tools
Tables
Bar Charts
Histograms
Pie Charts
Run charts
Statistical Process Control Charts
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48. Tables, Graphs, and Charts
Complete
Title describing the contents
Limited information
Labels describe the content
Make it concise and easily readable
If you use codes, abbreviations, or
symbols, use footnotes to explain
Monthly Surveillance Statistics
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49. Why Analyze, Display and
Report Data?
Tracking and Trending
Trends/changes overtime
Seasonal occurrences
Outbreaks
Sentinel events
Benchmarking/ Comparison
Compare to others
Detects areas for improvement
Use to improve performance
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50. BENCHMARKING
Benchmarking
is the process of
comparing oneself to others who are
performing similar activities, so as to
continuously improve.
The National Healthcare Safety
Network (NHSN)in the US is the oldest
and most widely used network for
benchmarking.
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51. Requirement for Successful
Benchmarking
Criteria for defining a case are standardized and up to date.
The population and time period for the study are well defined.
The surveillance methodology is standardized and consistently used
by all of the participants over time.
Rates and ratios are calculated using the same numerators (number
of cases) and denominators (population at risk).
All data collectors receive training on how to collect data and use a
standardized form.
The facility and population that is compared is similar to the types of
facilities and populations in an aggregate database used for external
comparison
NHSN Report 2010
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