Action 3.4

The health service organisation has a surveillance strategy for healthcare-associated infections and antimicrobial use that:

a. Collects data on healthcare-associated infections and antimicrobial use relevant to the size and scope of the organisation

b. Monitors, assesses and uses surveillance data to reduce the risks associated with healthcare-associated infections and support appropriate antimicrobial prescribing

c. Reports surveillance data on healthcare-associated infections and antimicrobial use to the workforce, the governing body, consumers and other relevant groups

Intent

Surveillance activities provide data to support patient safety and governance decisions in preventing healthcare-associated infections, and antimicrobial stewardship.

Reflective questions

How does the health service organisation collect surveillance data on healthcare-associated infections?

How are these data used to monitor, assess and reduce risks relating to healthcare-associated infections?

How are these data reported to the workforce, the governing body, consumers and other relevant groups?

Key tasks

  • Use information from the organisational risk management system to decide appropriate surveillance activities for the size and scope of the organisation.

  • Review existing surveillance processes to identify any gaps, changes or variation in data.

  • Ensure that existing processes and supporting policies include reporting of infection and resistance data to the relevant workforce, the governing body, consumers and other relevant groups.

  • Ensure that surveillance activities use nationally agreed definitions (if available) and meet state or territory requirements.

  • Ensure that the workforce performing surveillance activities is adequately trained.

  • Develop new surveillance activities if there is a change in the services provided.

Strategies for improvement

Hospitals

Identify the types of surveillance activities to be used

Surveillance strategies should support infection prevention and control activities, and be used to identify gaps and set priorities for action to minimise the risk of preventable healthcare-associated infections. Surveillance activities are determined by the complexity of the health service organisation, the services it provides, and national and state or territory requirements. Surveillance activities may include continuous surveillance; targeted, process or signal surveillance; or unit-based activities based on local, national, and state or territory requirements.

Surveillance activities may be used to monitor:

  • Staphylococcus aureus bacteraemia
  • Clostridium difficile infection
  • Central line-associated bloodstream infection
  • Catheter-associated urinary tract infection
  • Surgical site infection (for example, joint replacement, cardiac and maternity)
  • Ventilator-associated complications
  • Multidrug-resistant organisms of significance
  • Compliance with outbreak management processes in the health service organisation
  • Intravascular devices removed because of complications compared with those removed at the end of treatment
  • Consistency of antimicrobial prescribing with evidence-based Australian therapeutic guidelines
  • Post-discharge infection data from other health service organisations, clinicians or general practitioners.

The organisation may also take part in national surveillance activities relating to antimicrobial stewardship, such as the National Antimicrobial Prescribing Survey.

Review the organisation’s services, and identify opportunities for monitoring infections and resistance of microorganisms based on risk, national and state or territory requirements, or changes in the services provided by the organisation.

Review validation and training requirements

Use nationally agreed surveillance definitions (if available) and validate data collected (if applicable). Undertaking surveillance activities and validating data require the workforce involved to be trained in these techniques.

Communicate results of surveillance

Use the results of surveillance activities to inform the risk management process, and to review or develop policies, procedures and protocols to reduce the risk of healthcare-associated infections.

Ensure that processes are in place to interpret surveillance results and provide results to the relevant workforce, the organisation’s governing body (through the committee responsible for infection prevention and control), consumers and any other relevant groups.

Further resources on surveillance systems and infection surveillance definitions are available at the National Surveillance Initiative of the Australian Commission on Safety and Quality in Health Care (the Commission).

Related actions

In addition to these strategies, Action 3.16 includes specific strategies for the use of surveillance data on antimicrobial resistance and use to support appropriate prescribing.

Day Procedure Services

Identify the types of surveillance activities to be used

Surveillance strategies should support infection prevention and control activities, and be used to identify gaps and set priorities for action to minimise the risk of preventable healthcare-associated infections. Surveillance activities are determined by the complexity of the day procedure service, the services it provides, and national and state or territory requirements. Surveillance activities may include continuous surveillance; targeted, process or signal surveillance; or unit-based activities based on local, national, and state or territory requirements.

Examples of surveillance activities include:

  • Identification of infections
  • Identification of patients who re-present to clinicians with infections after treatment
  • Compliance with outbreak management processes in the health service organisation
  • Review of new patient assessment forms for infection risk that may influence treatment
  • Review of antimicrobial prescribing for consistency with evidence-based Australian therapeutic guidelines
  • Participation in national surveillance activities relating to antimicrobial stewardship, including the National Antimicrobial Prescribing Survey.

Review the organisation’s services, and identify opportunities for monitoring infections and resistance of microorganisms based on risk, national and state or territory requirements, or changes in the services provided by the organisation.

Assess and measure consistency with the policies, procedures and protocols of the overarching health service organisation or corporate group, if appropriate.

Review validation and training requirements

Use nationally agreed surveillance definitions (if available) and validate data collected (if applicable). Undertaking surveillance activities and validating data require the workforce involved to be trained in these techniques.

Communicate results of surveillance

Use the results of surveillance activities to inform the risk management process, and to review or develop policies, procedures and protocols to reduce the risk of healthcare-associated infections.

Ensure that processes are in place to interpret surveillance results and provide results to the relevant workforce, the organisation’s governing body (through the committee responsible for infection prevention and control), consumers and any other relevant groups.

Further resources on surveillance systems and infection surveillance definitions are available at the National Surveillance Initiative of the Australian Commission on Safety and Quality in Health Care (the Commission).

Examples of evidence

Select only examples currently in use:

  • Surveillance strategy for healthcare-associated infections based on the complexity of services provided in the health service organisation and assessment of risks
  • Audit results of surveillance activities for healthcare-associated infections
  • Reports of surveillance activities for healthcare-associated infections provided to the workforce, the governing body, consumers and other relevant groups
  • Results from analysis of data on healthcare-associated infections
  • Committee and meeting records in which surveillance data on healthcare-associated infections were reported or discussed.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established system for surveillance of healthcare-associated infections.

Small hospitals that are not part of a local health network or private hospital group should:

  • Use information from the organisational risk management system to determine appropriate surveillance activities for the size and scope of the organisation
  • Review existing surveillance processes to identify any gaps, changes or variation in data
  • Ensure that existing processes and supporting policies include reporting of infection and resistance data to the relevant workforce, the governing body, consumers and other relevant groups
  • Ensure that surveillance activities use nationally agreed definitions (if available) and meet state or territory requirements
  • Ensure that the workforce performing surveillance activities is adequately trained
  • Develop new surveillance activities if there is a change in the services provided.

Surveillance activities may be used to monitor:

  • Catheter-associated urinary tract infection
  • Multidrug-resistant organisms of significance
  • Compliance with outbreak management processes in the health service organisation
  • Intravascular devices removed because of complications compared with those removed at the end of treatment
  • Compliance with policy on management and removal of invasive devices used in the MPS or small hospital
  • Review of antimicrobial prescribing for consistency with evidence-based Australian therapeutic guidelines
  • Assessment of infection risks for new patients referred to the MPS or small hospital
  • Review of patients who re-present with infection risks that may influence treatment or management
  • Review of the incident management and investigation system for infection-related incidents and how they were managed
  • Participation in local and national surveillance activities relating to antimicrobial stewardship, including the National Antimicrobial Prescribing Survey.1

Use the results of surveillance activities to inform the risk management process, and to review or develop policies, procedures and protocols to reduce the risk of healthcare-associated infections.

Further resources on surveillance systems and infection surveillance definitions are available at the National Surveillance Initiative of the Australian Commission on Safety and Quality in Health Care (the Commission).2

Questions to consider when determining which surveillance activities should be undertaken include:

  • Does the organisation insert or manage invasive devices?
  • Does the organisation assess infection risks of patients?
  • How are data collected, reviewed and used in the organisation?
Last updated 21st June, 2018 at 07:44pm
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