By Kelly M. Pyrek
Even in the age of public reporting, there still exists a chasm between the healthcare institutions that use electronic surveillance systems (ESSs) in their infection prevention and control programs and those that do not. And according to experts, there is little known about the characteristics of hospitals that have an ESS, user satisfaction with ESSs, and organizational support for implementation of ESSs.
Patti G. Grota, RN, CNS-MS, MS, CIC, at Texas Health Science Center San Antonio, and colleagues, took it upon themselves to gather more data on the topic of ESS, and with the participation of the Association for Professionals in Infection Control and Epidemiology (APIC), conducted a Web-based survey of acute-care hospitals in California. Of the 350 invited facilities, 207 hospitals agreed to participate. The survey included a description of infection prevention and control department staff, where and how they spent their time, a measure of organizational support for infection prevention and control, and reported experience with ESS. This study was one component of a larger parent project, the Changing Role of Infection Preventionists, funded by the Blue Shield of California Foundation to evaluate the California Healthcare-Associated Infection Prevention Initiative (CHAIPI).
What Grota and her fellow researchers discovered was that just 23 percent of the participating hospital infection prevention and control programs had an ESS, a surprise, since one study indicated that use of an ESS decreased the time spent conducting surveillance by up to 61 percent, and because ESSs could potentially improve efficiency of data collection and patient outcomes. Grota says, however, "The use of ESS in infection control programs is in its infancy of development and implementation so the ramifications of not using ESSs are still being explored."
Grota and her colleagues report that among the 192 facilities that provided data on use of an ESS, 44 (23 percent) had an ESS. Of those, 52 percent reported using either a customized system or did not specify the system used; the other 48 percent used one of four commercial products (AICE, 32 percent; Medmined, 20 percent; Safety Surveillor, 9 percent; and Theradoc, 2 percent). Respondents reported that the ESS was used in their hospitals primarily to create reports and data summaries from built-in templates (77 percent), to provide automatic alerts (57 percent), to integrate infection data with Centers for Disease Control and Prevention definitions and/or reporting requirements (43 percent), for data mining (36 percent), and for sharing reports with committees and administration (61 percent).
Surveillance can be a time-consuming and demanding task for infection preventionists, and as Grota, et al. (2010) point out, "With the increasing availability and use of electronic medical records, information technology tools have created opportunities for automation of data collection and the potential to decrease the time spent on conducting manual surveillance. In a systematic literature review, it has been reported that infection prevention and control experts have predicted that the use of an ESS would allow them more time to provide leadership to clinicians to implement evidence-based processes aimed at reducing infections."
This time management component was addressed in the survey, with a categorization of activities based on the practice analysis published by the Certification Board of Infection Control and Epidemiology (CBIC). Respondents were asked to estimate the proportion of their work time spent in eight activities: surveillance; teaching infection prevention and control policies and procedures; activities related to outbreaks; daily isolation issues; policy development and meetings; other, such as product evaluation, workman's compensation, and research; employee/occupational health; and emergency preparedness. Respondents also were asked to estimate the proportion of their time spent in the IP office, inpatient areas, outpatient areas and long-term care areas.
As Grota, et al. (2010) write, "It was hypothesized that facilities with an ESS would spend less time in surveillance as automated surveillance replaced manual surveillance. In fact, a reported benefit of automation is improved resource utilization, saving about 10 weeks of infection control time annually and requiring only 1/6 to 1/3 of the time required for standard manual surveillance. However, we did not find that IPs in hospitals with an ESS devoted less time to surveillance activities or spent more time on education or with patients. Although ESS technology is increasingly used by IPs for data mining (i.e., reporting trends in organisms and/or infections), such systems have been used only minimally by infection prevention staff to help make decisions about necessary interventions. The IP using an ESS should be able to spend less time on data mining and more time on data analysis and patient care."
"I found it interesting that there were no differences reported in the type of infection control activities between hospitals with ESSs and those without ESSs," Grota says. "I expected that there would be less time used in surveillance and more time in consultation, unit rounds, and teaching in hospitals with ESS than hospitals without ESSs. The lack of difference may be related to the lack of sensitivity of the survey tool." She adds, "The implementation of ESSs was not expected to decrease teaching. Teaching or education is often used as a primary corrective action when problems are identified. It was expected to decrease time in surveillance, particularly in manual medical record surveillance, analysis, and trending. I think that the sensitivity of the tool used to assess time spent on activities in this study can be improved to better capture activities. For instance, surveillance, collecting, analyzing, and interpreting data was one category rather than separated into different categories of measurement. I think this is important because ESSs help more with surveillance, collecting and analyzing than it does with interpreting. In fact, it has the potential to discover more issues that need interpreting than do manual surveillance because of the technological power in automation."
Grota, et al. (2010) write, "Several reports have acknowledged that ESSs may not necessarily save time. Rather, data mining can detect new and unexpected patterns and may require additional human resources to analyze and develop interventions. Implementing an ESS involves a large investment in both dollars and human resources and requires the support of an organization that understands and values patient safety and potential cost savings though prevention of infections. An estimated 4,000 hours is required for the development of an internal clinical data warehouse for infection control, and costs do not end with development and implementation. Although ESSs have been shown to be efficient and effective in screening for potential outbreaks and identifying endemic healthcare-associated infections, the data generated electronically must be interpreted and translated into knowledge, drawing on the critical thinking skills of the IP. This paradigm shift to automated surveillance should allow the IP to minimize the time required to identify infections and maximize time spent in prevention, focusing on education and interventions aimed at reducing health care expenditures and adverse outcomes. The IP could then focus on leading intervention teams to reduce infections through implementation of evidence-based infection prevention practices, such as central lineassociated bloodstream infection and ventilator-acquired pneumonia prevention bundles."
Grota says that healthcare institutions with strong organizational support frequently have ESSs, and adds, "The trend toward ESS was reflective of facilities with larger number of beds but more importantly was the factor of organizational support. ESSs are costly and require leadership commitment to purchase and maintain. ESS implementation is also dependent on the commitment of the infection prevention leadership." Grota continues, "I know from experience in implementing a commercial ESS at my facility that ESS takes time to execute effectively and requires modification in workload assignments and procedures. On the other hand, it improves the ability to analyze concurrent data rather than retrospective data promoting corrective action in a more timely fashion. ESSs also allow for spending less time on data entry and more time on analysis and corrective actions although with electronic analysis more problems are sometimes identified increasing workload."
As Grota, et al. (2010) write, "ESSs provide the opportunity to spend less time on data collection and more time on decision making and implementing preventive interventions. These data suggest that in hospitals with strong leadership and engagement with patient safety, IPs in general may feel more supported in implementing ESSs and overcoming barriers, leading to greater satisfaction. This study clearly suggests that once an ESS is purchased, the need for organizational support has not ended; rather, both human and informatics resources must be committed to implementing and maintaining the program."
So, in some instances, data mining can actually create more work but yield richer results, Grota says, particularly with outbreak investigations or focused reviews. "In addition, ESS supports concurrent (vs. retrospective) data analysis improving the timeliness in identifying problems and implementing corrective actions. The end results is improving patient care and providing patient safety more efficiently," Grota adds. "I have sold the facility that employees me on the purchase and implementation of a commercial ESS package. We are going into our second year of implementation. It is important to get buy-in from as many stakeholders as possible to enhance its cost-effectiveness and its value. For instance, the ESS program that I use is beneficial to laboratory, nursing, pharmacy, as well as infection prevention. Cost savings can be reported particularly in laboratory and pharmacy because of its use. We use it for public health reporting, surveillance and trending of SSI, CLABSI, VAP, CR UTI, CDAD, and MDROs, antibiotic susceptibility tracking, and isolation bed management. It also flags us in our Microsoft Outlook immediately of any unusual pathogens so that we do not miss them on surveillance or delay finding them due to manual surveillance."
With mandated CLABSI reporting to the NHSN beginning this month, ESSs could provide welcome assistance. "Some ESS programs can be utilized to quickly identify positive blood cultures by unit, date of admission, date of culture and organism," Grota says. "Then the infection preventionist's time can be dedicated to classifying the CLABSI as primary or secondary, community-acquired or healthcare-acquired. The ESS that I use allows for setting up a template that will export important data elements from the electronic medical record into a worksheet eliminating the need for pencil and paper information and manual data entry."
So, as we welcome in 2011, many institutions and their infection prevention programs still teeter on the edge of a "great divide" between old-school paper and next-generation electronic systems. Whether to cross that divide remains as an important decision for facilities watching their bottom line yet striving for improved quality and patient outcomes.
"Organizational support absolutely plays into the ability for facilities and IPS to cross that great divide from paper to electronics," Grota says. "ESSs only work if there is already commitment and implementation of an electronic medical record. In general, the facility must have initiated that movement from paper to electronics for ESS to be useful and efficient. IPs at university and Veterans Affairs facilities are interested in implementing ESS. IPs are aware that as mandatory reporting is established, the importance of ESSs will increase to them and to the organization."
Reference: Grota PG, Stone PW, Jordan S, Pogorzelska M and Larson E. Electronic surveillance systems in infection prevention: Organizational support, program characteristics, and user satisfaction. Am J Infect Control. Vol. 38, No. 7, Pages 509-514. September 2010.