Action 3.05 states
The health service organisation has a surveillance strategy for infections, infection risk, and antimicrobial use and prescribing that:
- Incorporates national and jurisdictional information in a timely manner
- Collects data on healthcare-associated and other infections relevant to the size and scope of the organisation
- Monitors, assesses and uses surveillance data to reduce the risks associated with infections
- Reports surveillance data on infections to the workforce, the governing body, consumers and other relevant groups
- Collects data on the volume and appropriateness of antimicrobial use relevant to the size and scope of the organisation
- Monitors, assesses and uses surveillance data to support appropriate antimicrobial prescribing
- Monitors responsiveness to risks identified through surveillance
- Reports surveillance data on the volume and appropriateness of antimicrobial use to the workforce, the governing body, consumers and other relevant groups
Systems are in place to support and promote prevention and control of infections, improve antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources in the health service organisation.
- What process and outcomes measures are collected for the surveillance of infection, infection prevention and control processes and antimicrobial stewardship?
- How is information from local, jurisdictional and national surveillance programs used to monitor, assess and reduce risks relating to infections?
- How are outcomes from surveillance reported to the workforce, the governing body, consumers and other relevant groups? How is feedback from these groups used?
- How can the organisation contribute to existing surveillance that is coordinated by their governing, or networked, healthcare organisation(s)?
- What surveillance methods are in place to monitor antimicrobial use and how are they used? In what forum are they discussed and reviewed?
- How does the organisation compare to other similar services with respect to antimicrobial use?
Examples of evidence
- Evidence of strategies used for the surveillance of infection prevention and control processes and outcomes that are appropriate for the local epidemiology, complexity of the care and treatment provided by organisation
- Evidence of strategies used for the surveillance of antimicrobial stewardship processes and outcomes that are appropriate for the local epidemiology, complexity of the care and treatment provided by organisation
- Evidence of audit processes for monitoring infection prevention and control processes (for example, hand hygiene, environmental cleaning and aseptic technique audits)
- Reports of surveillance activities for infections that are provided to the workforce, governing body, consumers and other relevant groups
- Demonstration of how results of surveillance activities are used to inform the risk management process, and to review or develop policies, procedures and protocols to reduce the risk of infections, for example, quality improvement plans and action plans
- Evidence of participation in mandatory and non-mandatory national surveillance activities relevant to infection prevention and control and antimicrobial stewardship
- Evidence of the organisation reviewing and locally responding to national and/or jurisdictional infection prevention and control and antimicrobial stewardship surveillance outcomes
- Committee and meeting records in which surveillance data on infections are reported and discussed
- Evidence of review of and response to local data from existing national infection prevention and control and antimicrobial stewardship monitoring systems (for example, infection surveillance programs such as the National Alert System for Critical Antimicrobial Resistances (CARAlert), Australian Passive AMR Surveillance, hospital-acquired complications and readmissions data, ion, antimicrobial prescribing and use, implementation of the National Hand Hygiene Initiative incident management systems, PROMS data, the National Notifiable Diseases Surveillance System)
- Examples of evidence-based systems that are used to address risks identified through surveillance activities such as use of transmission-based precautions, environmental cleaning or hand hygiene programs