HLB

Successful surveillance programs are dependent on definitions and data collection methods that are clear and consistent (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2012; CDCD, 2014). In WA, the “Healthcare-Associated Infection Surveillance in Western Australia Policy” (Department of Health Western Australia, 2019) directs HAI surveillance. HISWA developed the policy and a surveillance manual with HAI specific definitions and criteria for reporting to support it. Specific HAI indicators have been developed based on national and international definitions to allow for accurate and meaningful data collection and timely detection of trends (CDCD, 2014).

As healthcare leaders, it is essential to evaluate whether the HAI definitions and criteria are clearly understood and implemented. Local processes need to be developed and continually monitored to ensure accurate data collection consistent with State definitions. In WA, HISWA undertakes forums or workshops quarterly, to ensure that surveillance methodology is clearly understood, allowing for robust data that is informative and useful. Questionnaires or quizzes may be used to gain an understanding of relevant knowledge.

All acute care facilities should have dedicated trained ICPs to undertake and manage infection control (IC) programs, including HAI surveillance (NHMRC, 2019; WHO, 2016). ICPs are required to provide expert consultancy facility-wide and perform the ongoing evaluation of the program’s success. Not all people undertaking infection surveillance activities are appropriately trained, leading to reduced agreement when identifying HAIs (NHMRC, 2019). The level of skills can be evaluated by ensuring that ICPs in acute care facilities have the relevant qualifications and experience. In private facilities in WA, it is a requirement of the Licensing and Accreditation Regulatory Unit that private ICPs provide evidence of their qualifications as part of the licensing process (Government of Western Australia, 2017). A key performance indicator (KPI) for this input could be the number of qualified ICPs (measured in full-time equivalent) per occupied beds in each acute care facility in WA.

Clinical governance and supportive executive leadership are crucial to the success of all IC programs (ACSQHC, 2017; NHMRC, 2019). IC programs should be considered a priority in all healthcare facilities (HCFs), with the overall responsibility being that of the most senior leader in the organization (NHMRC, 2019). Governance can be monitored by ensuring that executive members are part of IC committees, where relevant surveillance information, methods, and results are discussed and minuted. In WA governance is further ensured in that surveillance data is submitted to HISWA, analyzed, and the results disseminated to all participating Chief Executive Officers (CEOs) in quarterly aggregate reports (Healthcare Associated Infection Unit, 2019-20), creating awareness and accountability.

As it is challenging for larger organizations to perform facility-wide surveillance, activities are channeled towards higher-risk procedures, population groups, or medical devices e.g., centrally inserted intravascular devices (NHMRC, 2019). The KPIs monitored in WA are outlined in the HISWA manual and a brief overview of appropriate processes or methods suggested. Processes, wherever possible, include investigating all microbiology results, daily ward rounds and review of patient records, use of patient management systems or infection prevention surveillance systems, discussion or notification from clinical staff and medical referrals e.g., from infectious diseases physicians (CDCD, 2014).

At an organizational level, these processes need to be monitored and evaluated to ensure that the information received is timely, complete, and accurate. For example, all microbiology results need to be investigated daily in order to detect trends or potential surveillance KPIs. Microbiology results may be missed if the process for delivery of results is not evaluated. An evaluation question may, therefore, be “Were all microbiology results received for a certain period?” with the indicator for this throughput being the number of microbiology results received over the total number processed by the laboratory. Also, the collection of accurate denominator data is required e.g., central line days in intensive care (ICU). Central line-associated bloodstream infections in ICU are one of the HISWA KPIs; therefore, the process of denominator data collection needs to be monitored and reviewed.

Data validation is essential in ensuring that the data collected for surveillance purposes is accurate and reliable (CDCD, 2014; Kuster, Eisenring, Sax, & Troillet, 2017). In WA, validation is undertaken by HISWA contributors at an organizational level but also by HISWA at a State level in the form of surveillance workshops or during validation visits to individual hospitals. Internal methods should include cross-checking of infections detected with coding reports, checking infections against HISWA raw data reports, discussing surgical site infections with a relevant surgeon, cross-checking with consolidated laboratory reports, and double-checking bed day data reports with administrators (CDCD, 2014). Data validation is a form of monitoring, and evaluating the process of surveillance, ensuring that valid data is submitted for analysis and benchmarking. It is a crucial part of the surveillance program.

HISWA contributors are required to submit and finalize their surveillance data monthly for the preceding month, using an online HISWA database (CDCD, 2014). The purpose of data submission to a state body is to facilitate analysis and interpretation of data across WA to enable internal and external benchmarking and identify trends or concerns in infection rates (Department of Health Western Australia, 2019; Groseclose & Buckeridge, 2017). An evaluation question for this throughput could be “Do all participating hospitals submit their surveillance data within the specified timeframe?" and the indicator could be the proportion of hospitals that submitted their data on time. Timely data submission and analysis need to be sustained in order to identify trends and provide feedback to all relevant stakeholders.

The main aim of collecting accurate and meaningful surveillance data is to use it to improve the quality of healthcare (ACSQHC, 2017; NHMRC, 2019). High-quality data is necessary to meet the program objectives, which are to use the data to identify potential issues and influence change (Groseclose & Buckeridge, 2017). Accurate data could be evaluated by measuring the proportion of contributing hospitals that submitted accurate data against the required HAI indicators. For example, did all hospitals submitting HAI Staphylococcus aureus blood stream infection data, submit accurate, validated data within the required timeframe.

Detecting changes or trends in HAI rates allows clinicians to identify and investigate potential problem areas and implement appropriate interventions (ACSQHC, 2012; CDCD, 2014; Groseclose & Buckeridge, 2017). Trends are monitored and benchmarked at both State and organizational level and assist with evaluating the efficacy of infection prevention measures (CDCD, 2014). As a healthcare leader, it is imperative to ensure that these HAI trends are monitored continuously, and that timely feedback is provided to all key stakeholders in order to initiate prompt, efficient investigations and interventions.

Timely feedback on HAI surveillance data results in reduced HAI rates (ACSQHC, 2012; CDCD, 2014). HISWA executive reports are provided to the executive teams of all contributing HCFs every quarter (HISWA, 2019-20). These reports contain trending data as well as key points relevant to each HAI indicator. Information regarding report interpretation and trending data is provided in the HISWA manual, the intention being that the information is used to drive change and improvement at both organizational and state level (CDCD, 2014; Department of Health Western Australia, 2019). It is vital to ensure that these reports are succinct and provide the required information to all key stakeholders. Questionnaires could be distributed to key stakeholders and feedback sought on the layout or level of understanding. The output indicator might be the proportion of HCFs with a full understanding of the trending data and its implication to implement change.

Figure 1. Input-throughput-output model for healthcare-associated infection surveillance in Western Australia

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