224C. King et al. / Journal of Hospital Infection 82 (2012) 219e226<strong>Risk</strong> <strong>factors</strong> assessed: 143(47 risk <strong>factors</strong> were notstatistically significant)Significant risks: 96Independent risks: 43Located in localhospital data: 39PAR% calculated: 35(one of which wasinsignificant)Located in localhospital data: 28PAR% calculated: 26(one of which wasinsignificant)PAR% <strong>and</strong> located in localhospital data: 24PAR% <strong>and</strong> located in localhospital data: 18Figure 2. Schematic of the numbers of significant <strong>and</strong> independent risk <strong>factors</strong> at different stages in the methodology. All those risk<strong>factors</strong> that are independent are also significant, whereas those risk <strong>factors</strong> that are significant but not independent may only have beenconsidered in univariate analysis or became insignificant when confounders were taken into account in multivariate analysis. Significantrisk <strong>factors</strong>, P-value of
C. King et al. / Journal of Hospital Infection 82 (2012) 219e226 225how to code conditions, <strong>and</strong> in<strong>for</strong>mation on when they are tobe recorded are provided by the NHS (available at: http://www.connecting<strong>for</strong>health.nhs.uk/codingclinic). 46 The mostrecent guidelines specify a group of comorbidities to bem<strong>and</strong>atorily coded within administrative hospital data if thereis any mention of them in the patient’s medical notes, including<strong>urinary</strong> retention, renal failure <strong>and</strong> diabetes. 46 However,despite clear guidance, poor-quality coding is still reported. 47Issues arise from variability in coders <strong>and</strong> <strong>their</strong> experience,<strong>and</strong> the detail <strong>and</strong> accuracy of the in<strong>for</strong>mation contained withinthe patient’s medical notes. In order to create surveillancetools using administrative data, these quality issues need to betaken into consideration, with an underst<strong>and</strong>ing of the potential<strong>for</strong> the under or over-recording of codes.In the absence of a real-time medical record, the applicationof surveillance <strong>for</strong> HCA UTI based on predictors at anindividual level is not plausible. The delay often encounteredwith administrative data means that data on risks, such asdiabetes mellitus, are only available electronically once thepatient has been discharged. Centres such as Salt Lake City,where electronic patient records have been implemented <strong>for</strong>20 years, have shown the potential <strong>for</strong> this technology in aidingsurveillance of HCAI. 48 Certain hospital data, such as pathology<strong>and</strong> radiology in<strong>for</strong>mation, are recorded electronically as theyare processed, suggesting that real-time syndromic surveillancecould be developed based on these data. This has beenimplemented successfully in the USA <strong>for</strong> catheter-<strong>associated</strong>bloodstream <strong>infection</strong>s. 49 However, the use of predictors todevelop surveillance at the hospital population level usingadministrative data is possible with prospective applications.This includes implementing a risk stratified framework <strong>for</strong> HCAUTI surveillance, the creation of benchmarking tools <strong>for</strong> HCAUTI which account <strong>for</strong> local patient populations, <strong>and</strong> theopportunity to monitor interventions <strong>and</strong> control measures.The use of different administrative hospital data systems todevelop novel surveillance systems is still an emerging discipline,<strong>and</strong> with over 750 individual databases located thus farwithin ICHNT, further relevant in<strong>for</strong>mation on risk <strong>factors</strong> islikely to be stored routinely within the hospital data. Electronicsurveillance represents a cost-effective, time-efficient <strong>and</strong>robust approach to surveillance, although it is subjective toclinical opinion <strong>and</strong> a changing policy l<strong>and</strong>scape. 50 In thecontext of HCA UTI, this could potentially provide a system tocomplement traditional surveillance schemes <strong>and</strong> <strong>infection</strong>prevention <strong>and</strong> control practices across <strong>healthcare</strong> settings.Despite the methodology in this paper being based upon theadministrative data found routinely within the UK NHS, theauthors believe that the principle is applicable to any healthsystem with electronic administrative data.This study has demonstrated the potential of local administrativehospital data <strong>for</strong> the development of innovativesurveillance <strong>for</strong> HCA UTI by applying the results froma systematic literature review to local administrative datausing a novel methodology, despite the various limitationsdiscussed. This work has provided the basis <strong>for</strong> a framework tofurther explore the benefits of using hospital data in thedevelopment of surveillance tools <strong>for</strong> HCA UTI. The next stepsare to investigate the utility <strong>and</strong> quality of the codes identifiedby this review in local data, apply this to developing riskprofiles <strong>and</strong> proxy indicators, <strong>and</strong> test the value of syndromicalgorithms to enhance traditional surveillance <strong>and</strong> <strong>infection</strong>control approaches.Conflict of interest statementNone declared.Funding sourcesThe UK Clinical Research Collaboration funds the NationalCentre <strong>for</strong> Infection Prevention <strong>and</strong> Management at ImperialCollege London, <strong>and</strong> also supports the UK National Institute<strong>for</strong> Health Research Biomedical Research Centre fundingscheme. The Dr Foster Unit at Imperial is largely funded bya research grant from Dr Foster Intelligence (an independenthealth service research organization) <strong>and</strong> is affiliatedwith the Centre <strong>for</strong> Patient Safety <strong>and</strong> Service Quality atImperial College Healthcare NHS Trust, funded by theNational Institute <strong>for</strong> Health Research.AcknowledgementsThe authors wish to thank the Infection Prevention <strong>and</strong>Control, Pathology <strong>and</strong> Microbiology departments <strong>and</strong> theIn<strong>for</strong>mation Technology teams within Imperial College NHSTrust <strong>for</strong> <strong>their</strong> collaboration.References1. World Health Organization. WHO guidelines on h<strong>and</strong> hygiene inhealth care: first global patient safety challenge e clean care issafer care. Geneva: WHO; 2009.2. Plowman R, Graves N, Esquivel J, Roberts JA. 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