Syndrome surveillance: It’s back to the future

Once upon time, there were no computers’

Tired of sitting in her office and conducting her program in front of the computer screen, an infection control professional got some good old paper in hand and hit the wards to talk to health care workers. Suddenly she was in "real time," recalls Rita Tjoelker, RN, MS, CIC, infection control clinical nurse specialist at Veterans Affairs Medical Center in Portland, OR.

"This isn’t anything new," she says. "It is just the pendulum swinging."

Tjoelker and colleagues developed a syndrome-based strategy to conduct surveillance for nosocomial infections. Their longstanding approach had consisted of using lab-generated microbiology computerized reports, then looking up cases on personal office computers.

Feeling out of touch

"Everything that I need to look at now is on a computer screen," she says. "It makes it very, very tough to force myself to get out of my office. We found more and more that we were feeling out of touch and not as visible as we used to be."

Moreover, Tjoelker suspected she may be missing timely case findings because computerized microbiology data are typically a few days old. In addition, direct care staff were becoming less aware of what types of patient concerns they should report to the ICPs. To overcome the problem, they developed syndrome surveillance, an approach that includes tools to provide guidance for the ICP in asking staff to identify clusters of similar symptoms in patients. (See box, p. 125.)

ICPs monitor acute inpatient units for unusual clusters of infections among patients or employees by making routine rounds and interviewing key staff. The surveillance is "problem-oriented" by design so investigations can be rapidly initiated. Health care workers are also advised to look for common illnesses or sentinel events within the medical staff, providing possible clues to occupational outbreaks.

Outbreaks identified

The program was implemented last October, and Tjoelker says it has since triggered rapid investigations of several outbreaks. Those include two outbreaks of diarrhea-like illness in staff; an outbreak of methicillin-resistant Staphylococcus aureus in an intensive care unit (ICU); and a flu-like illness in an affiliated long-term care setting. None of these clusters would have been identified — certainly not as quickly — by relying on computer surveillance alone, she says.

"We would have picked up the ICU outbreak of MRSA probably, but it would have been four or five days old," Tjoelker says. "Your time for teaching and heightening awareness is kind of gone."

Instead, by directly questioning the workers on the unit, she learned of several patients that had apparent infections. Some of the patients had been admitted with MRSA, but others had become infected within the ICU, she found. Discovering the outbreak provided opportunities for increased visibility and teaching, she emphasized. Similarly, using the syndrome surveillance approach, ICPs found out that several nurses had been stricken with diarrhea within a short time span.

"We figured out who the [index] patient was, who probably had something [enteric] that was not culture confirmed," she says. "Then the nurses had a little potluck [dinner] in the break room. It was a very real-time example of why you don’t have food in the immediate patient care areas."

The program heightens awareness of infection control in general, and boosts outreach and education at a time of rapid staff changes and turnover nationally.

"It’s hard to measure the impact of it, because we are doing a lot of this one on one," she says. "We have a huge a staff, and sometimes it seems I am never talking to the same person because we have a lot of agency staff. We do spend a lot of time with the frontline managers, and that is a fairly stable group."

Of course, her computer surveillance is still used to complement the effort, says Tjoelker, a veteran of eight years in the profession. "I think that this would be a very good tool for a new ICP. Even though I am experienced, I still find it helpful. It reminds me that once upon time there were no computers."

Ironically, cutting-edge discussions of bioterrorism repeatedly stress looking for syndromes in the absence of cultures, which may not be available quickly enough to recognize an event is unfolding. "What’s old is new again," she says.