American Journal of Infection Control 44 (2016) 482-4
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief report
Infection surveillance systems in primary health care: A literature review Mary Lou Manning PhD, CRNP, CIC, FAAN *, Monika Pogorzelska-Maziarz PhD, MPH Jefferson College of Nursing, Thomas Jefferson University, Philadelphia, PA
Key Words: Accountable care act outpatient clinics community health centers
The Patient Protection and Affordable Care Act of 2010 is placing primary care at the epicenter of accountability of US health care delivery. There is a significant body of evidence characterizing the value of acute-care hospital infection surveillance systems. Given the central role primary care is beginning to play, we were interested in examining the use of infection surveillance systems in primary care practice. Our review of the literature found only 2 articles describing the influence of primary care infection surveillance systems, both providing evidence of its benefits. This area is ripe for further research. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Infection surveillance in US acute care hospitals took root in 1970 when the Centers for Disease Control and Prevention launched the National Nosocomial Infections Surveillance System.1 In 2005 the Centers for Disease Control and Prevention integrated the National Nosocomial Infections Surveillance System, the Dialysis Surveillance Network, and the National Surveillance of Healthcare Workers to create the National Healthcare Safety Network (NHSN).2 NHSN provides health care facilities with data that aid in the prevention of health care-associated infections by identifying changes in infection rates and sites, risk factors, outcomes, and pathogens. In recent years, NHSN surveillance efforts have been extended outside the acute care setting to include outpatient dialysis and ambulatory surgical centers, long-term acute care hospitals, psychiatric and rehabilitation hospitals, and nursing homes.3 Despite this expansion, acute care hospitals and dialysis facilities represent the majority of facilities in the reporting data. Moreover, little attention has been given to the use of infection surveillance systems in primary care. The Patient Protection and Affordable Care Act (ACA) of 2010 is changing the way US health care is financed and delivered. As many as 16 million Americans are newly insured as a result of the ACA—a number projected to reach 32 million.4,5 Accountable care organizations and the patient-centered medical home are primary care models promoted by the ACA. Primary health care is delivered in various settings, including individual office-based practices, hospital outpatient clinics, community health centers, and integrated
* Address correspondence to Mary Lou Manning, PhD, CRNP, CIC, FAAN, Jefferson College of Nursing, Thomas Jefferson University, 901 Walnut St, Rm 814, Philadelphia, PA 19107. E-mail address: [email protected] (M.L. Manning). Conflicts of Interest: None to report.
care systems. Primary care practice has become increasingly complex as providers strive to address patients’ acute, chronic, preventive, social, and behavior needs against a backdrop of formidable infectious disease threats to human health, including antibiotic resistance and unexpected infections such as pandemic influenza. Recognizing the seismic shift in care patterns from inpatient to outpatient settings and the central role primary care is beginning to play, we were interested in examining the use of infection surveillance systems in these settings. We conducted a literature review to examine the use of infection surveillance systems in primary care practice and to assess the effectiveness and feasibility of such systems. METHODS In collaboration with a research librarian, we searched 3 electronic databases: Ovid Medline, Ovid Medline In-process, and Scopus. In addition to using controlled vocabulary in Medline, we combined the term infection with terms defining surveillance such as track, monitor, assess, screen, and prevent, and terms that indicate a primary care setting such as primary care, outpatient clinic, community, physician office, nurse managed clinics, and patient centered medical home. Article inclusion criteria were published between January 1, 2003, and January 29, 2015; written in the English language; published in a peer-reviewed journal; and content related to existing infection surveillance in a primary care setting in the United States. Exclusion criteria included editorials, commentaries, abstracts, conference proceedings, and discussions of the subject; articles related to ambulatory specialty care clinics (eg, HIV clinic and sexually transmitted disease clinic) or ambulatory specialty centers (eg, surgical centers, dialysis centers, and infusion centers);
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.11.004
M.L. Manning, M. Pogorzelska-Maziarz / American Journal of Infection Control 44 (2016) 482-4
articles describing dedicated disease-specific surveillance such as hepatitis or HIV; outbreak investigations not based on an existing infection surveillance system; and articles describing epidemiologic surveillance established as part of research studies. The authors independently reviewed study titles and abstracts for overall relevance. Together they then discussed the rationale for remaining articles based on the aforementioned inclusion and exclusion criteria. Articles that appeared to meet the inclusion criteria were read in full text. Reference lists of articles read in full were also checked. RESULTS As shown in Figure 1, the search strategy yielded a total of 225 articles. Two hundred seven were excluded because they did not meet our inclusion criteria, primarily because they were related to ambulatory specialty care clinics and centers or described dedicated disease specific surveillance, and/or surveillance that was established as part of research studies. The full text of 18 articles was read and only 2 were identified as meeting the inclusion criteria. Both studies described the use of electronic infection surveillance systems in primary care at university health care systems to track respiratory viral infections. A summary of each follows. Influenza-like illness surveillance
Screening
Identification
Baker and colleagues6 describe the performance and utility of a local combined syndromic and electronic medical record (EMR)derived influenza-like illness (ILI) surveillance system at 8 sites associated with a Virginia university health care system. Sites within the hospital complex included internal medicine primary care, family medicine primary care, obstetrics and gynecology, employee health clinics, and the emergency department. Sites outside the hospital complex included satellite internal medicine primary care and pediatrics clinics, and the University Student Health Clinic, which provides ambulatory care for more than 21,000 students. Each site
reported the number of ambulatory patient encounters with ILI by clinical or coding criteria and the total number of patients seen. Data were collected daily throughout the influenza season. The authors found that data from this local ILI surveillance system were available several days sooner than data from the state and regional ILI systems, provided the ability to follow ILI rates at the individual clinics, and detected early onset of respiratory illness in the student health clinic. The authors concluded that the surveillance system was effective in providing real-time, useful, accessible, and accurate information that led to important organizational changes in resource allocation, including staffing of an influenza-specific clinic and implementing a telephone flu hotline. Respiratory virus surveillance Syndor and colleagues7 describe the use of an electronic respiratory virus surveillance system using TheraDoc clinical surveillance software (Premier, Inc., Charlotte, NC) at a university-based outpatient care continuum clinic serving low-risk hematopoietic stem cell transplant recipients. Year-round electronic query of respiratory virus test results were performed twice weekly outside of respiratory virus season and then daily once respiratory virus cases were detected. The authors found that the use of the surveillance system allowed for the early detection of a human parainfluenza virus 3 outbreak in the clinic occurring outside of the peak respiratory virus season resulting in the rapid implementation of effective infection control measures. An outbreak investigation found that the majority of human parainfluenza virus 3 cases were acquired in the clinic. DISCUSSION Advances in medical care, improved disease prevention practices, and an aging population have all increased the medical complexity of patients who receive primary care in the United States.8 What is more, due to the provisions in the ACA the number of people
225 records identified through search of three electronic databases
225 titles and abstracts screened
Inclusion
Eligibility
16 articles removed:
18 full text articles assessed for eligibility
483
-Surveillance established as part of research study (n=6) -Dedicated disease specific surveillance (n=3) -Outside of the U.S. (n=3) -Outbreak investigation not based on existing surveillance system (n=1) -Outside of primary care (n=1) -Not peer-reviewed (n=1) -Not infection surveillance (n=1)
2 studies selected for inclusion in qualitative synthesis
Fig 1. Flow diagram describing the identification, screening, eligibility, and inclusion of studies.
484
M.L. Manning, M. Pogorzelska-Maziarz / American Journal of Infection Control 44 (2016) 482-4
receiving primary care has increased dramatically. Despite the increasing patient complexity and exploding patient volume our results indicate that there are few primary care sites using infection surveillance systems; systems that might potentially aid in early identification and response to an infectious disease-related event. The primary care sites using infection surveillance systems that we did find were limited to university health care systems using an EMR and focused only on identifying respiratory tract symptoms and infections. Although Baker et al6 demonstrated that a combination of primary care-based syndrome and EMR surveillance data were effective in providing accurate, dynamic, and easily accessible data, the data spanned only 1 influenza season and the system measured ILI rather than confirmed cases of influenza. On the other hand, Syndor et al7 tailored year-round electronic surveillance to query respiratory virus test results, leading to early detection and containment of a respiratory virus outbreak in an at-risk population. Despite the limitations both studies provide some beginning evidence of the potential benefits of using targeted infection surveillance in primary care. It must be noted that conducting such surveillance at small private primary care practices without an EMR and with limited infection control resources would require considerable effort. Future research should examine the effectiveness, feasibility, cost, and value of implementing infection surveillance systems in various types of primary care settings. This review was limited by the inclusion of only articles in English, articles focused on existing infection surveillance in primary care settings in the United States, and search terms used for primary care. Clearly, it is possible that studies were missed. Nonetheless, we believe this is the first literature review focused on examining infection surveillance systems in primary health care. Opportunities to study the influence of infection surveillance systems across the care continuum should emerge as the locus of primary care delivery shifts from small private practices to integrated health care
systems using an EMR system.8 Novel surveillance methods linked to the primary care setting must be developed not only for infectious disease surveillance, but also to measure the influence of infection prevention and control practices and to grow an evidence base for best practice in primary care.9 Acknowledgment The authors thank Patricia Wynne, associate university librarian for information and clinical support, Thomas Jefferson University, for assisting with the literature review. References 1. Gaynes RP, Culver DH, Emori G, Horan TC, Banerjee SN, Edwards JR, et al. The National Nosocomial Infections Surveillance System: plans for the 1990a and beyond. Am J Med 1991;91(Suppl 3B):116S-120S. 2. Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen-Bridson K, Morrell G, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009;37:783-805. 3. Centers for Disease Control and Prevention. National Healthcare Safety Network. Available from: http://www.cdc.gov/nhsn/about-nhsn/index.html. Accessed September 15, 2015. 4. Blumenthal D, Abrams M, Nuzum R. The affordable care act at five. N Engl J Med 2015;372:2451-8. 5. Goodson JD. Patient protection and affordable care act: Promise and peril for primary care. Ann Intern Med 2010;152:742-4. 6. Baker AW, Enfield K, Mehring B, Turner JC, Sifri CD. Local influenza-like illness surveillance at a university health system during the 2009 H1N1 influenza pandemic. Am J Infect Control 2012;40:606-10. 7. Syndor ER, Greer A, Budd AP, Pehar M, Munshaw S, Neofytos D, et al. An outbreak of human parainfluenza virus 3 in an outpatient hematopoietic stem cell transplant clinic. Am J Infect Control 2012;40:601-5. 8. Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff 2010;29:799-805. 9. Saiman L. More support to reduce the burden of respiratory illnesses through improved infection prevention and control in ambulatory settings. Infect Control Hosp Epidemiol 2014;35:257-8.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief report
Infection surveillance systems in primary health care: A literature review Mary Lou Manning PhD, CRNP, CIC, FAAN *, Monika Pogorzelska-Maziarz PhD, MPH Jefferson College of Nursing, Thomas Jefferson University, Philadelphia, PA
Key Words: Accountable care act outpatient clinics community health centers
The Patient Protection and Affordable Care Act of 2010 is placing primary care at the epicenter of accountability of US health care delivery. There is a significant body of evidence characterizing the value of acute-care hospital infection surveillance systems. Given the central role primary care is beginning to play, we were interested in examining the use of infection surveillance systems in primary care practice. Our review of the literature found only 2 articles describing the influence of primary care infection surveillance systems, both providing evidence of its benefits. This area is ripe for further research. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Infection surveillance in US acute care hospitals took root in 1970 when the Centers for Disease Control and Prevention launched the National Nosocomial Infections Surveillance System.1 In 2005 the Centers for Disease Control and Prevention integrated the National Nosocomial Infections Surveillance System, the Dialysis Surveillance Network, and the National Surveillance of Healthcare Workers to create the National Healthcare Safety Network (NHSN).2 NHSN provides health care facilities with data that aid in the prevention of health care-associated infections by identifying changes in infection rates and sites, risk factors, outcomes, and pathogens. In recent years, NHSN surveillance efforts have been extended outside the acute care setting to include outpatient dialysis and ambulatory surgical centers, long-term acute care hospitals, psychiatric and rehabilitation hospitals, and nursing homes.3 Despite this expansion, acute care hospitals and dialysis facilities represent the majority of facilities in the reporting data. Moreover, little attention has been given to the use of infection surveillance systems in primary care. The Patient Protection and Affordable Care Act (ACA) of 2010 is changing the way US health care is financed and delivered. As many as 16 million Americans are newly insured as a result of the ACA—a number projected to reach 32 million.4,5 Accountable care organizations and the patient-centered medical home are primary care models promoted by the ACA. Primary health care is delivered in various settings, including individual office-based practices, hospital outpatient clinics, community health centers, and integrated
* Address correspondence to Mary Lou Manning, PhD, CRNP, CIC, FAAN, Jefferson College of Nursing, Thomas Jefferson University, 901 Walnut St, Rm 814, Philadelphia, PA 19107. E-mail address: [email protected] (M.L. Manning). Conflicts of Interest: None to report.
care systems. Primary care practice has become increasingly complex as providers strive to address patients’ acute, chronic, preventive, social, and behavior needs against a backdrop of formidable infectious disease threats to human health, including antibiotic resistance and unexpected infections such as pandemic influenza. Recognizing the seismic shift in care patterns from inpatient to outpatient settings and the central role primary care is beginning to play, we were interested in examining the use of infection surveillance systems in these settings. We conducted a literature review to examine the use of infection surveillance systems in primary care practice and to assess the effectiveness and feasibility of such systems. METHODS In collaboration with a research librarian, we searched 3 electronic databases: Ovid Medline, Ovid Medline In-process, and Scopus. In addition to using controlled vocabulary in Medline, we combined the term infection with terms defining surveillance such as track, monitor, assess, screen, and prevent, and terms that indicate a primary care setting such as primary care, outpatient clinic, community, physician office, nurse managed clinics, and patient centered medical home. Article inclusion criteria were published between January 1, 2003, and January 29, 2015; written in the English language; published in a peer-reviewed journal; and content related to existing infection surveillance in a primary care setting in the United States. Exclusion criteria included editorials, commentaries, abstracts, conference proceedings, and discussions of the subject; articles related to ambulatory specialty care clinics (eg, HIV clinic and sexually transmitted disease clinic) or ambulatory specialty centers (eg, surgical centers, dialysis centers, and infusion centers);
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.11.004
M.L. Manning, M. Pogorzelska-Maziarz / American Journal of Infection Control 44 (2016) 482-4
articles describing dedicated disease-specific surveillance such as hepatitis or HIV; outbreak investigations not based on an existing infection surveillance system; and articles describing epidemiologic surveillance established as part of research studies. The authors independently reviewed study titles and abstracts for overall relevance. Together they then discussed the rationale for remaining articles based on the aforementioned inclusion and exclusion criteria. Articles that appeared to meet the inclusion criteria were read in full text. Reference lists of articles read in full were also checked. RESULTS As shown in Figure 1, the search strategy yielded a total of 225 articles. Two hundred seven were excluded because they did not meet our inclusion criteria, primarily because they were related to ambulatory specialty care clinics and centers or described dedicated disease specific surveillance, and/or surveillance that was established as part of research studies. The full text of 18 articles was read and only 2 were identified as meeting the inclusion criteria. Both studies described the use of electronic infection surveillance systems in primary care at university health care systems to track respiratory viral infections. A summary of each follows. Influenza-like illness surveillance
Screening
Identification
Baker and colleagues6 describe the performance and utility of a local combined syndromic and electronic medical record (EMR)derived influenza-like illness (ILI) surveillance system at 8 sites associated with a Virginia university health care system. Sites within the hospital complex included internal medicine primary care, family medicine primary care, obstetrics and gynecology, employee health clinics, and the emergency department. Sites outside the hospital complex included satellite internal medicine primary care and pediatrics clinics, and the University Student Health Clinic, which provides ambulatory care for more than 21,000 students. Each site
reported the number of ambulatory patient encounters with ILI by clinical or coding criteria and the total number of patients seen. Data were collected daily throughout the influenza season. The authors found that data from this local ILI surveillance system were available several days sooner than data from the state and regional ILI systems, provided the ability to follow ILI rates at the individual clinics, and detected early onset of respiratory illness in the student health clinic. The authors concluded that the surveillance system was effective in providing real-time, useful, accessible, and accurate information that led to important organizational changes in resource allocation, including staffing of an influenza-specific clinic and implementing a telephone flu hotline. Respiratory virus surveillance Syndor and colleagues7 describe the use of an electronic respiratory virus surveillance system using TheraDoc clinical surveillance software (Premier, Inc., Charlotte, NC) at a university-based outpatient care continuum clinic serving low-risk hematopoietic stem cell transplant recipients. Year-round electronic query of respiratory virus test results were performed twice weekly outside of respiratory virus season and then daily once respiratory virus cases were detected. The authors found that the use of the surveillance system allowed for the early detection of a human parainfluenza virus 3 outbreak in the clinic occurring outside of the peak respiratory virus season resulting in the rapid implementation of effective infection control measures. An outbreak investigation found that the majority of human parainfluenza virus 3 cases were acquired in the clinic. DISCUSSION Advances in medical care, improved disease prevention practices, and an aging population have all increased the medical complexity of patients who receive primary care in the United States.8 What is more, due to the provisions in the ACA the number of people
225 records identified through search of three electronic databases
225 titles and abstracts screened
Inclusion
Eligibility
16 articles removed:
18 full text articles assessed for eligibility
483
-Surveillance established as part of research study (n=6) -Dedicated disease specific surveillance (n=3) -Outside of the U.S. (n=3) -Outbreak investigation not based on existing surveillance system (n=1) -Outside of primary care (n=1) -Not peer-reviewed (n=1) -Not infection surveillance (n=1)
2 studies selected for inclusion in qualitative synthesis
Fig 1. Flow diagram describing the identification, screening, eligibility, and inclusion of studies.
484
M.L. Manning, M. Pogorzelska-Maziarz / American Journal of Infection Control 44 (2016) 482-4
receiving primary care has increased dramatically. Despite the increasing patient complexity and exploding patient volume our results indicate that there are few primary care sites using infection surveillance systems; systems that might potentially aid in early identification and response to an infectious disease-related event. The primary care sites using infection surveillance systems that we did find were limited to university health care systems using an EMR and focused only on identifying respiratory tract symptoms and infections. Although Baker et al6 demonstrated that a combination of primary care-based syndrome and EMR surveillance data were effective in providing accurate, dynamic, and easily accessible data, the data spanned only 1 influenza season and the system measured ILI rather than confirmed cases of influenza. On the other hand, Syndor et al7 tailored year-round electronic surveillance to query respiratory virus test results, leading to early detection and containment of a respiratory virus outbreak in an at-risk population. Despite the limitations both studies provide some beginning evidence of the potential benefits of using targeted infection surveillance in primary care. It must be noted that conducting such surveillance at small private primary care practices without an EMR and with limited infection control resources would require considerable effort. Future research should examine the effectiveness, feasibility, cost, and value of implementing infection surveillance systems in various types of primary care settings. This review was limited by the inclusion of only articles in English, articles focused on existing infection surveillance in primary care settings in the United States, and search terms used for primary care. Clearly, it is possible that studies were missed. Nonetheless, we believe this is the first literature review focused on examining infection surveillance systems in primary health care. Opportunities to study the influence of infection surveillance systems across the care continuum should emerge as the locus of primary care delivery shifts from small private practices to integrated health care
systems using an EMR system.8 Novel surveillance methods linked to the primary care setting must be developed not only for infectious disease surveillance, but also to measure the influence of infection prevention and control practices and to grow an evidence base for best practice in primary care.9 Acknowledgment The authors thank Patricia Wynne, associate university librarian for information and clinical support, Thomas Jefferson University, for assisting with the literature review. References 1. Gaynes RP, Culver DH, Emori G, Horan TC, Banerjee SN, Edwards JR, et al. The National Nosocomial Infections Surveillance System: plans for the 1990a and beyond. Am J Med 1991;91(Suppl 3B):116S-120S. 2. Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen-Bridson K, Morrell G, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009;37:783-805. 3. Centers for Disease Control and Prevention. National Healthcare Safety Network. Available from: http://www.cdc.gov/nhsn/about-nhsn/index.html. Accessed September 15, 2015. 4. Blumenthal D, Abrams M, Nuzum R. The affordable care act at five. N Engl J Med 2015;372:2451-8. 5. Goodson JD. Patient protection and affordable care act: Promise and peril for primary care. Ann Intern Med 2010;152:742-4. 6. Baker AW, Enfield K, Mehring B, Turner JC, Sifri CD. Local influenza-like illness surveillance at a university health system during the 2009 H1N1 influenza pandemic. Am J Infect Control 2012;40:606-10. 7. Syndor ER, Greer A, Budd AP, Pehar M, Munshaw S, Neofytos D, et al. An outbreak of human parainfluenza virus 3 in an outpatient hematopoietic stem cell transplant clinic. Am J Infect Control 2012;40:601-5. 8. Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff 2010;29:799-805. 9. Saiman L. More support to reduce the burden of respiratory illnesses through improved infection prevention and control in ambulatory settings. Infect Control Hosp Epidemiol 2014;35:257-8.
