Recommended practices for surveillance. Association for Professionals in Infection Control and Epidemiology, Inc. Surveillance Initiative working Group.

Demonstration of quality health care includes documentation of outcomes of care. Surveillance is a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the health care team to assist in improving those outcomes. Surveillance is an essential component of effective clinical programs designed to reduce the frequency of adverse events such as infection or injury. Although there is no single or "right" method of surveillance design or implementation, sound epidemiologic principles must form the foundation of effective systems and must be understood by key participants in the surveillance program and supported by senior management. Teamwork and collaboration across the health care spectrum are important for the development of surveillance plans. Each health care organization must tailor its surveillance systems to maximize resources by focusing on population characteristics, outcome priorities, and organizational objectives. To ensure quality of surveillance, the following elements must be incorporated: A written plan should serve as the foundation of any surveillance program. The plan should outline important objectives and elements of the surveillance process so that resources can be targeted appropriately. Thoroughness or intensity of surveillance for an area of interest must be maintained at the same level over time. Fluctuations of a surveillance rate have no meaning unless the same level of data collection is maintained. External rate comparisons are meaningless unless the systems used have comparable intensity. All the elements of surveillance should be used with consistency over time. This includes application of surveillance definitions and rate calculation methods. Personnel resources need to be appropriate for the type of surveillance being performed. This includes trained professionals who understand epidemiology and who have access to continuing professional education opportunities. Other resources essential to surveillance include computer support, information and technology services, clerical services, and administrative understanding and support to maintain a quality program. As a means of quality control and to ensure accuracy, the data and process of surveillance should undergo periodic evaluation and validation. This document is intended to assist professionals who plan and conduct surveillance programs as well as those who assure that there is appropriate organizational support to accomplish appropriate surveillance. While design of surveillance systems must be unique for each organization, incorporation of these seven core Recommended Practices for Surveillance provides a scientific framework to approach surveillance programs.

Differences in mortality after fracture of hip: the east Anglian audit.

OBJECTIVE: To investigate differences between hospitals in clinical management of patients admitted with fractured hip and to relate these to mortality at 90 days. DESIGN: A prospective audit of process and outcome of care based on interviews with patients, abstraction from records with standard proforma, and follow up at three months. Data were analysed with chi 2 test and forward stepwise regression modelling of mortality. SETTING: All eight hospitals in East Anglia with trauma orthopaedic departments. PATIENTS: 580 consecutive patients admitted for fracture of neck of femur. MAIN OUTCOME MEASURE: Mortality at 90 days. RESULTS: Patients admitted to each hospital were similar with respect to age, sex, pre-existing illnesses, and activities of daily living before fracture. In all, 560 (97%) were treated surgically, by a range of grades of surgeon. Two hundred and sixty one patients (45%; range between hospitals 10-91%) received pharmaceutical thromboembolic prophylaxis, 502 (93%; 81-99%) perioperative antibiotic prophylaxis. The incidence of fatal pulmonary emboli differed between patients who received and those who did not receive prophylaxis against deep vein thrombosis (P = 0.001). Mortality at 90 days was 18%, differing significantly between hospitals (5-24%). One hospital had significantly better survival than the others (odds ratio 0.14; 95% confidence interval 0.04-0.48; P = 0.0016). CONCLUSIONS: No single factor or aspect of practice accounted for this protective effect. Lower mortality may be associated with the cumulative effects of several aspects of the organisation of treatment and the management of fracture of the hip, including thromboembolic pharmaceutical prophylaxis, antibiotic prophylaxis, and early mobilisation.

Coming home. Work, family and services in the 1990s and beyond.

The current trend of the 1990s appears to be one of increased work at home, home-manufactured products, and home-delivered services. Corporations, both large and small, are struggling to address the changing needs of working-age women and men as they attempt to strike a balance between career and family. The home care community, already deeply dedicated to family-focused care and keeping families together, is in an excellent position to expand services to meet the growing demand.

Private pensions: will the money be there when you retire?

There is clear evidence that Social Security, even when taken together with the benefits of a private pension plan, may not be adequate income for America's future retirees. Employees must begin planning and implementing long-term savings strategies now to make up the difference.

The incidence of meningococcal illness in the East Anglian Regional Health Authority: 1990-1991.

The rate at which notifications of meningococcal meningitis were reported by districts of the East Anglian Regional Health Authority to the Office of Population Censuses and Surveys (OPCS) varied between 6.8 and 28.0 cases per million resident population per year between 1987 and 1991. A study was conducted to find out whether this variation represented differences in incidence, completeness of notification, or reporting practices. One hundred and one cases of meningococcal illness with onset between 1 January 1990 and 31 December 1991 were identified retrospectively in residents of the East Anglian region (population 2.06 million). The ascertained incidence of meningococcal illness was 24.5 cases/million/year with a range between districts of 13.1 to 35.7 cases/million/year, similar to that expected from national data. Most of the variation in the rates of reporting to OPCS was explained by the practices of two consultants in communicable disease control (CCDCs), who reported all cases of which they were aware, irrespective of statutory notification. The study showed that communication to CCDCs was sometimes inadequate, and that control measures were not instituted in a small proportion of cases. The recommendations resulting from this study are, firstly, that OPCS should produce clear guidelines for notification and reporting. In the meantime proper officers should make their reporting practice explicit. Secondly, a sensitive case definition for meningococcal illness is needed for local monitoring of prophylactic coverage. Thirdly, CCDCs, microbiologists, clinicians, and environmental health officers should review arrangements for data exchange.