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• Articulate infection, incidence, and prevalence rates, stratified risk assessments, and antibiotic
Experiential Learning Portfolio Guide Each of these objectives will be further discussed and will include reflection on how I have met their
resistance patterns
• Apply theories and best practice to the collection and interpretation of surveillance data

intent within my Infection Prevention program.

Systematic and Standardized Approach to Record Surveillance Data

A standardized approach to applying surveillance definitions is a key foundation of any infection
prevention program. Without knowledge of surveillance definition criteria, accurate rates and risk
assessment cannot occur. As an Infection Preventionist, I rely on the CDC’s National Healthcare
Safety Network (NHSN) surveillance definitions. These surveillance definitions allow for objective
assessment by an Infection Preventionist in determining if an infection is healthcare associated (CDC,
2016). My program’s surveillance plan includes device/procedure associated infections such as
central line associated bloodstream infections (CLABSI), catheter associated urinary tract infections
(CAUTI), surgical site infections (SSI), and ventilator associated events (VAE), as well as surveillance
for methicillin resistant Staphylococcus aureus, vancomycin resistant Enterococcus, and Clostridium
difficile healthcare associated infections. Infections present on admission and those that are considered
healthcare-associated employ standardized criteria across the Infection Prevention discipline in
order to assist Infection Preventionists in objectively determining presence of healthcare associated
infection status. This is extremely important as the Centers for Medicare and Medicaid (CMS) issues
reimbursement penalties based on poor performance related to select value based purchasing and
patient safety indicators. These include certain healthcare acquired infections that we are trusted to
identify using NHSN surveillance definitions.

As an Infection Preventionist, I follow the previously mentioned surveillance plan as directed by
the Infection Prevention Committee. As an electronic database to assist with data collection and
surveillance does not currently exist, manual methods are employed to log infection data into Microsoft
Excel spreadsheets. Select infection data is then entered into the CDC’S NHSN surveillance system per
CMS requirements. An electronic surveillance software system is in discussions which will aid in further
objectifying NHSN surveillance definitions as well as create time efficiencies that are not currently
possible because of manual surveillance systems and follow-up.

Analysis of Data Collection

As an Infection Preventionist, I analyze facility surveillance data and modify the Infection Prevention
Risk Assessment when necessary. This risk assessment is the driver of the program’s priorities. The
risk assessment scores select risks based on previously collected data and input from organizational
leaders. This allows any argument for the need for project improvement to be based on evidence/
facts and not on anecdotal hearsay. The analysis of surveillance data identifies trends that may
require performance improvement activities. Statistical process control charts are utilized to determine
if processes are in “control” or if any special cause variation has occurred, whether good cause or
bad cause. For example, an increased number of CLABSI were identified on the surgical floor and

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