Electronic Surveillance Systems Aid ICPs in Outbreak Investigation

by Michelle Beaver, Infection Control Today

Ideally, infections would pack up and go to Pluto. But since that’s not going to happen, infection control practitioners (ICPs) will continue to be busy with outbreak surveillance. Fortunately, several programs can save valuable time and remove uncertainty and inconsistency when it comes to tracking methicillin-resistant Staphylococcus aureus, Clostridium difficile, and other unwanted visitors.

Good automated surveillance systems can detect potential outbreaks early on, and provide that information to ICPs and epidemiologists clearly and quickly. This allows staff members to move fast and in a focused fashion.

An automated surveillance system is useless, however, without savvy staff members at the helm, says Salah Qutaishat, PhD, CIC, FSHEA, an epidemiologist and director of infection prevention and control at Premier Inc. healthcare alliance. Premier is a hospital performance improvement alliance with 1,700 participating not-for-profit hospitals and health systems nationwide. Its administrators collect and analyze clinical and financial data from its member hospitals, organize committees, sponsor seminars and conferences, and share best practices.

“An astute clinician is the most important element in detecting potential outbreaks and they are essential in providing guidance and direction in the prevention and control of these outbreaks,” Qutaishat says. “Automated surveillance systems are a supplement to the talent and expertise of these clinicians.”

Systems allow ICPs to be more efficient and to spend their time, “finding ways to prevent infections rather than digging through paper laboratory reports trying to identify them,” Qutaishat adds. The amount and extent of resources ranges widely between facilities, however, says Runa Dhar Whitaker, a director at RL Solutions, a software company that provides software systems to hospital and healthcare facilities.

“Surveillance may be for outbreaks, but may also be for a range of other things, such as day-to-day infection control and assessing how to prevent infections,” Dhar Whitaker says. “Typically, ICPs are unable to do as much surveillance or preventative contact as they would like to, but it does depend heavily on the facility, because some hospitals have one ICP per 100 beds, (while) others have one per 300 beds. Also, the range of tools provided for ICPs varies from none (other than Microsoft Excel) to some hospitals with in-house information that can provide a lot of support.”

And what is the bane of existence for most ICPs in regard to outbreak surveillance?

“Usually it is the frustration of not having sufficient resources to do the preventative and post-outbreak isolation etc., that is required to minimize the spread of the infection,” Dhar Whitaker says. “However, related to this is the frustration of having to do manual file creation and surveillance when this work could be done by a computerized system. Anything that will allow an ICP to get more time dealing with the issues on the ground is of help.”

What Does Automated Surveillance Do?

Surveillance systems monitor patient cultures. They use rules and algorithms to identify pathogen patterns and to realize when control limits have been exhausted, says Jeff Hodson, RN, BSN, CIC. He is also product manager for the TheraDoc® Infection Control Assistant®.

“Early recognition of pattern variance helps the ICP to stop an outbreak in progress, or possibly prevent an outbreak from occurring,” Hodson says.

The programs should also export data to Microsoft Excel, Microsoft Access and other programs. This type of efficient data management frees ICPs from manually reviewing laboratory and patient data, and instead allows them to focus their efforts on education and interventions, says G.T. LaBorde, a vice president of Cardinal Health, MedMined™ Services.

Efficient data management should include real-time, customizable event monitoring and reporting across an entire health system, according Med- Mined™ Services product designers. They suggest that surveillance programs should not require manual data entry. Furthermore, the programs should include patient details from present and past, and information on patient location, physicians, organism resistance, etc.

“The ability to have this electronic data and to be able to do surveillance across the hospital with the press of a button and then tie that data to financial data really has the ability to elevate infection control to really a different level in the organization,” LaBorde says.

“My advice is to think big about what you’d really like your department to be and do, not just limit it to data crunching and reporting,” LaBorde adds. “It may be that what technology or certain solutions allow you to do is change your whole department.”

It is becoming common knowledge that hospital-acquired infections (HAIs) cost the healthcare system dearly. Reducing infections requires an investment, but is worth it in the long run, both financially and in patient health.

Some automated surveillance systems help make the business case for infection prevention, and can convince the powers that be to invest in ICP resources. LaBorde says that MedMined™ Services customers often see an increase in their full-time equivalents (FTEs) when surveillance materials prove to administrators the financial impact of infections.

“You think, ‘Well, if you spend budget money to buy an electronic service then you wouldn’t be able to then justify additional FTEs — you’ve already spent your budget money,’” LaBorde says. “But what we find is that when you have this comprehensive surveillance methodology and you can tie that to the financial outcomes of the facility, you are able to illuminate for hospital administrators how big a problem this is not just to patient care but also to the bottom line of the hospital.”

Technology should not threaten jobs — it should support them.

“Some ICPs worry that technology will take their jobs away and really the opposite is true,” LaBorde says. “What our clients have seen is a net increase in staffing because they’re able to measure things objectively and financially justify infection control efforts.”

Once MedMined™ clinical tools identify an HAI, they tie that data to the hospital’s accounting system. This answers questions such as, “’What are the increased costs and length of stay and unprofitably when a patient gets an infection in that facility,’” LaBorde says. “’Who is the payor and how often does that happen? We can really have a conversation about the financial impact using (the hospital’s) own data. That becomes very important because the best hospitals are ones where the infection control team includes not only infection control practitioners, but the medical staff, central service and administration on one team.”

Such financial analysis and data presentation gets management excited and spurs the idea that it’s everyone’s responsibility to prevent infections, LaBorde says.

“You can take the data that gets generated from these tools and then that data gets fed into an environment to change behavior and improve outcomes,” he adds. “If that data doesn’t really motivate anyone outside the infection control office, then the investment you’ve made and the technology is useless. It’s only if you can marry the identification of opportunities to improve, with changing the entire culture of the hospital to act on those opportunities, that you get significant improvement.”

The basics of outbreak surveillance are the same nationwide, but each facility may have different needs. Plans should therefore have room for adjustment, says Qutaishat.

“Each hospital should have an infection control annual plan that constitutes the infection prevention blueprint for that facility,” he says. “This plan should be flexible enough to allow adjustment based on changes in the epidemiologic profile of the facility and the community. The staff should look at these automated surveillance systems as an extension of their existing annual infection control plan.”

Automated surveillance can be a rare break for the typically-overworked ICP.

“I think infection practitioners have ever-increasing areas of responsibility or demands on the department without an equal increase of resources with which to accomplish all of it,” LaBorde says. “One way that electronic surveillance is helping them to meet these multiple demands on their time is by making the day-to-day surveillance activities much more efficient.”

One specific program, data mining surveillance by MedMined™, is a patented methodology that identifies emerging issues in areas that may not be obvious.

“It watches your back for problem areas that you may not have suspected,” LaBorde says.

Several programs exist, and finding the right one for your facility means asking a lot of questions. This is not a short-term decision, LaBorde says.

“Shopping for a system may mean several things,” he says. “When you pick a company … understand that your information systems will change over time. It’s not really a static purchase. You really need to pick a company that has a history of success and stability and a commitment to the (infection control) community.”

LaBorde also suggests that consumers look at the total costs when choosing a product. For instance, does the sticker price include hardware, installation and training, or are those additional costs?

“You really can’t compare sticker price to sticker price,” he says. “You have to dig below and say, ‘What are the ownership costs over three or five years of using this, both internally and through what we pay the vendor?’”

Hospitals should involve ICPs and epidemiologists when they are shopping for an electronic solution, Hodson says.

“The ideal solution will continuously review and apply logic, algorithms, and rules to the data immediately (not in batch files), provide alerts to any variance in data patterns or for an organism of concern, compare susceptibility patterns for antimicrobials as part of the identification process, provide automated statistical comparison, and create reports that include complete data comparisons, descriptions and graphs that are commonly used by the ICP and public health communities,” Hodson says.

He suggests that shoppers pay special attention to how the software identifies multi-drug-resistant organisms, especially those that colonize.

No matter how great any product sounds, consumers should take their time before making a decision.

The MedCard by MedMined™ is one option for internal and external HAI reporting. Benchmarking capabilities allow hospitals to compare infection rates (type and location) by unit, hospital-wide and to other facilities throughout the country, product literature states.

The MedMined™ antimicrobial management reports trends, monitors process improvement actions and shows whether an issue is resolved. The alert classes can be customized.

Another product, TheraDoc’s Infection Control Assistant (ICA), provides continuous automated surveillance for unusual patterns of hospital-acquired and community-acquired microorganisms.

The ICA alerts the ICP immediately when usual, expected thresholds are broken and a possible outbreak has been identified. It identifies clusters of microorganisms for the ICP based on a number of factors, including antibiotic susceptibility patterns.

The ICA also provides patient data including vital signs, microbiology, lab, pharmacy, bed and surgery history.

TheraDoc also offers the Antibiotic Wizard® to help clinicians choose the right drug for each infection.

“TheraDoc allows ICPs to enter infections into the database in the absence of a clinical culture,” product managers state. “This is often seen in surgical site infections when a patient is culture negative, but has been treated for a surgical site infection by their physician. “This provides the most accurate data for reporting.”

A critical question to ask when looking for a surveillance system is, “What is the ease of use, and how will your company assist in training?”

Education is an essential component of the Premier program, says Qutaishat.

“The training includes technical aspects of using our automated system,” he says. “We also partner with facilities to establish plans focused on enhancing intervention efficiencies.”

LaBorde agrees that the relationship a hospital has with a surveillance product distributor should not end with the purchase.

“We provide services to hospitals, not just a piece of software or a tool,” LaBorde says. “We supplement all of those technologies with clinical and financial experts who help hospitals make sure that all of this technology is used to maximize its benefits to patients and the bottom line of the hospital.

“Part of our service is quite a lot of training prior to the go-live moment of the technology so that they’ll know what to expect and basic ways to use it,” LaBorde adds. “After that go-live time — which is about 60 days after the contract is signed — there is a lot of hands-on training on how to use different elements of it.”

Good technology should never be difficult to use and shouldn’t be intimidating, LaBorde says.

“Unfortunately, not all technology is engineered right,” he adds. “That’s why a lot of what we do has services wrapped around it … so that the tools don’t get in the way of doing the real job of teaching and the interventions that prevent infection.”

Hospital staff members and administrators are seeing that automation is needed throughout facilities, not just for infection control and epidemiology, Qutaishat says.

“At the present time, many hospitals continue to use paper medical records and handwritten progress notes that may add to the burden of interpretation of information contained within these records,” he says.

“Significant progress in enhancing patient safety and preventing healthcare- acquired infections can only be realized when automation is available at these facilities. …The goal is to transform infection control programs to move closer to the bedside.”

The biggest trend that LaBorde sees is that hospital staffs want to know more than ever before about the infections in their facilities.

“The CMS rule changes that will (soon) be effective will reduce the payments from Medicare to hospitals when HAIs occur,” LaBorde says. “Those rule changes don’t limit the infections to just those in critical care areas.

Those rules apply to patients throughout the facility, (which means) those hospitals that have previously employed targeted surveillance methodologies really will be at a disadvantage in terms of preventing infections in all the areas where CMS is about to stop paying for them. It is increasing the demand for ways of electronically identifying all the infections in a hospital so that administrators have a scope of how big a problem is and how best to address it.”

Surveillance is also changing in that fewer hospitals rely on good old fashioned pencils and notepads.

“The crudest method is the one that has been in place for the last 30 years, which is infection control practitioners spending a lot of time being chart abstractors and manually digging through piles of patient data, making their own judgments as to which patients have HAIs and then manually doing the computations and the graphing that flow from those numbers,” LaBorde says.

“I think most practitioners that I’ve spoken with want to be free from the paper chase because they know there are things going on in the hospital that they could improve but many are frustrated because they don’t have the time or the resources to get freed up from that daily paper chase to do all the interventions that they would like to do,” he adds. “It’s also bad for hospitals because there is inherent subjectivity to human beings making that determination of infection.”

Indeed, electronic surveillance trends support the ICP, Hodson says. “Hospitals without electronic assistance often require the ICP to request reviews of microbiology data to confirm any suspicions of variable patterns of pathogens,” he says. “This means that someone from the microbiology lab has to review and hand count numbers of isolates for any given set of criteria. Most often the entire process takes weeks to confirm any suspicions, or too often, the outbreak is well under way and includes several patients before measures are put in place to control it.

“If an ICP has the ability to look at microbiology lab data electronically, it can still be a slow process of importing data into spreadsheets, applying statistical process, and generating findings,” he adds.

With so many products on the market and so many differences in how humans can interpret results, inconsistency in reporting can be a big problem.

Groups of people can look at the same patient charts and come up with vastly different infection data, according to LaBorde.

“That inconsistency makes things like public reporting very doubtful,” he says. “How do you know it was counted the same way in hospital A as it was in hospital B? The data is not consistent and it’s really not the best that it can be.”

MedMined™ has a patent-pending electronic method of identifying infections that gives consistent data between hospitals, LaBorde says. Many infection control systems still rely on the practitioner to decide whether there was an outbreak, and that’s a problem, he adds.

“(Some systems) simply do the calculations and the graphing that flow from that, so you still have this inconsistency between hospitals or even in the same hospital, potentially,” he adds.

MedMined™ works with about 250 hospitals. The data is standardized.

“We ‘clean and map it’ so that when you apply the same algorithms that determine whether something is likely an HAI, you are doing it on data that is consistent between hospitals,” LaBorde says. “If each hospital did its own installation, even if you apply the same algorithm, if the way that you cleaned and mapped that data isn’t consistent, then the electronic algorithm is going to yield different numbers.”

Aggressive Staph Found to Secrete Compound That Attacks Immune Cells

WASHINGTON - The aggressive antibiotic-resistant staph infection responsible for thousands of recent illnesses undermines the body's defenses by causing germ-fighting cells to explode, researchers reported Sunday. Experts say the findings may help lead to better treatments.

An estimated 90,000 people in the United States fall ill each year from methicillin-resistant Staphylococcus aureus, or MRSA. It is not clear how many die from the infection; one estimate put it at more than 18,000, which would be slightly higher than U.S. deaths from AIDS.

The infection long has been associated with health care facilities, where it attacks people with reduced immune systems. But many recent cases involve an aggressive strain, community-associated MRSA, or CA-MRSA. It can cause severe infections and even death in otherwise healthy people outside of health care settings.

The CA-MRSA strain secretes a kind of peptide - a compound formed by amino acids - that causes immune cells called neutrophils to burst, eliminating a main defense against infection, according to researchers.

The findings, from a team of U.S. and German researchers led by Michael Otto of the National Institute of Allergy and Infectious Diseases, appeared in Sunday's online edition of the journal Nature Medicine.

While only 14 percent of serious MRSA infections are the community associated kind, they have drawn attention in recent months with a spate of reports in schools, including the death of a 17-year-old Virginia high school student.

Both hospital-associated and community-associated MRSA contained genes for the peptides. But their production was much higher in the CA-MRSA, the researchers said.

The compounds first cause inflammation, drawing the immune cells to the site of the infection, and then destroy those cells.

The research was conducted in mice and with human blood in laboratory tests.

Within five minutes of exposure to the peptides from CA-MRSA, human neutrophils showed flattening and signs of damage to their membrane, researchers said. After 60 minutes, many cells had disintegrated completely.

‘‘This elegant work helps reveal the complex strategy that S. aureus has developed to evade our normal immune defenses,'' Dr. Anthony S. Fauci, NIAID director, said in a statement. ‘‘Understanding what makes the infections caused by these new strains so severe and developing new drugs to treat them are urgent public health priorities.''

Dr. George G. Zhanel, a medical microbiologist at the University of Manitoba in Canada, said the study was the first he had seen that identifies the peptides involved.

This shows at least one of the reasons CA-MRSA is able to cause serious problems, Zhanel, who was not part of the research team, said in a telephone interview. Findings like this may help lead to better treatments, such as ways to neutralize the peptides or to activate the immune system to defeat them, he added.

Dr. Lindsey N. Shaw of the division of cell biology, microbiology and molecular biology at the University of South Florida, also was enthusiastic about the research.

‘‘Specifically identifying a factor which seemingly makes CA-MRSA more pathogenic than HA-MRSA is a real find,'' Shaw, who was not part of the research group, said via e-mail. The ‘‘molecules identified in the study are indeed novel.''

Zhanel noted that while hospital-based MRSA seemed to concentrate on ‘‘sick old people,'' the community-based strain can break out in on sports teams, prisons, cruise ships and other places where people are not necessarily sick or have weakened immune systems.

In a worrisome development, he noted that the more aggressive strains have started appearing in hospitals.

Dr. Clarence B. Creech, an assistant professor of pediatric infectious disease at Vanderbilt University, said every time scientists find a new way that staph uses to make people sick, ‘‘we open up the field of developing new vaccine targets and new drug targets.''

‘‘This is one of the papers we can look to as we develop new vaccines and drugs,'' Creech, who was not part of the research team, said in a telephone interview.

The research was funded by the National Institutes of Health, the German Research Council and the German Ministry of Education and Research.