Since the first edition of this book, there has been a great deal of discussion and debate among professionals over the desirability of continuing routine surveillance, argued by some to be too personnel-time-intensive in an era of constrained hospital budgets. As this discussion continues, an account of the development of concepts and techniques of surveillance should be considered. Many of these techniques were developed to meet emerging problems, and the basic concept of surveillance has been found effective in reducing HAI risk. Knowledge of the historical reasons for these developments may help improve the efficiency and effectiveness of surveillance without discarding the well-conceived approaches that remain effective.

The use of surveillance methods to control HAIs dates back at least to the classic work of Dr. Ignaz Semmelweis in Vienna in the 1840s (4). Although the Semmelweis story is best remembered as the first demonstration of person-to-person spread of puerperal sepsis and of the effectiveness of handwashing with an antiseptic solution, an equally important achievement was Semmelweis’ rigorous approach to the collection, analysis, and use of surveillance data. In contrast, the concurrent work of Dr. Oliver Wendell Holmes on the same subject in the United States was based primarily on the traditional anecdotal case-study approach of clinical medicine.

Semmelweis’ investigation constitutes an amazingly contemporary example of the effective use of surveillance in addressing a widespread HAI problem. When he assumed the directorship of the obstetric service at the Vienna Lying-in Hospital in 1847, Semmelweis noted that the apparent risk of maternal mortality had been at high levels for >20 years. The eminent clinicians of the day, in fact, considered the risks to be no more than the expected endemic occurrence that could not be influenced. Semmelweis first undertook a retrospective investigation of maternal mortality and set up a prospective surveillance system to monitor the problem and, later, the effects of control measures. The initial results of his retrospective study of annual hospital mortality showed clearly that the maternal mortality level, which he measured by calculating yearly mortality rates, had increased 10-fold following the introduction in the 1820s of the new anatomic school of pathology, which used autopsy as its primary teaching tool. On the basis of the use of ward-specific mortality, Semmelweis calculated that the risk of death on the ward used for teaching medical students was at least four times higher than that on the ward used for teaching midwifery students. After the septic death of his mentor suggested the presence of a transmissible agent, Semmelweis used the findings from his retrospective surveillance study to implicate the practices of the medical students. After observing their daily routines, he surmised that students might be transferring “cadaver particles” from cadavers to the parturient women and that washing hands with a chlorine solution might prevent this transmission. Subsequently, his prospective surveillance data documented a dramatic reduction in maternal mortality immediately following the institution of mandatory handwashing before entering the labor room.

Apparently, due to his abrasive manner, lack of diplomacy, and inability to organize his statistical data into a concise and convincing report, Semmelweis failed to win over his clinical colleagues to his discovery. Within 2 years, he was dismissed from the staff of the hospital, and his successor gradually allowed the strict handwashing measures to decline. In the absence of continuing surveillance, the epidemic promptly resumed and lasted well into the early part of the 20th century, its
severity and means of prevention apparently unappreciated by several more generations of clinicians.

This story illustrates one of the main impediments to infection prevention and control today: in the absence of carefully collected epidemiologic data and a diplomatic presentation, clinicians, who are oriented almost entirely toward the treatment of individual patients, often fail to appreciate the severity of the HAI pathogen-transmission problem and sometimes resist control measures. It also points out the utility of surveillance in identifying problems and developing and applying control measures. From a methodologic viewpoint, Semmelweis’ efforts encompassed almost all aspects of the modern surveillance approach: retrospective collection of data to confirm the presence of a problem; analysis of the data to localize the risks in time, place, and person; controlled comparisons of high- and low-risk groups to identify risk factors; formulation and application of control measures; and prospective surveillance to monitor the problem, evaluate the implemented control measures, and detect future recurrences. The main shortcoming of his approach was in not diplomatically educating his powerful colleagues with a careful report of his findings.

Despite Semmelweis’ historical model, the modern era of HAI surveillance grew more from mid-20th century experience. The importance of surveillance for disease control in general arose in the effort to control tropical diseases among troops stationed in the Pacific Theater in World War II. At the end of the war, most of the epidemiologists of the “Malaria Control in War Areas Unit” were transferred to a civilian facility to apply their surveillance and control strategies to the control of malaria in the southern United States. Located in Atlanta, near the endemic areas, the unit was first named the Communicable Diseases Center and later became the Centers for Disease Control and then the Centers for Disease Control and Prevention (CDC). Since the large number of reports of malaria indicated the disease to be widespread, a surveillance system was immediately set up to define the extent of the problem. However, as investigators examined each reported case, they found virtually all of the reports had errors in diagnosis. Thus, the mere activity of surveillance “eradicated” the malaria epidemic in the United States.

Because of this and similar successes, when the pandemic of staphylococcal infections swept the nation’s hospitals in the mid-1950s, CDC staff members were quick to apply the concepts of surveillance to the problem (5). When asked to assist in investigating a staphylococcal epidemic in a particular hospital, these early investigators often met strong resistance from clinicians, and hospital administrators convinced that no unusual infection problems were present in their hospitals. In instances when CDC staff members were able to continue the investigations, the collection and reporting of surveillance data regularly changed those attitudes to strong concern over the documented problems and eagerness to apply control measures. These initial investigations thus confirmed a nationwide staphylococcal epidemic and led the CDC to sponsor several national conferences to discuss the problem.

By the early 1980s, some critics were questioning the effectiveness and cost-benefit of routine HAI surveillance although a growing number of hospitals were increasing their surveillance efforts rather than cutting them back (6). Surveillance was, and remains, a time-consuming activity, requiring about 40% to 50% of the time of an infection preventionist (IP) (7).

Several factors have influenced contemporary practices favoring robust surveillance activities in infection prevention and control programs. First, the results of the Study on the Efficacy of Nosocomial Infection Control (SENIC) project strongly substantiated the importance of surveillance along with prevention and control measures to reduce HAI rates and provided the scientific basis for surveillance of HAIs (8). The conclusion was that hospitals that are effective in reducing their HAI rates have an organized, routine, hospital-wide surveillance system. Second, the requirements of the Joint Commission on Accreditation of Healthcare Organizations (TJC, formerly JCAHO) have legitimized the need for personnel to perform surveillance (9,10). Third, the surveillance practices developed in infection control have begun to influence other aspects of the hospital’s quality monitoring and improvement activities (11). The strategies of targeting surveillance to reduce specific endemic problems and monitoring to assess the intervention’s effectiveness were incorporated into TJC’s 1994 infection control standards for accreditation and were applied to hospital quality-assurance programs to reduce noninfectious complications (12).

The increasing pressure to continually improve quality has broadened the use of surveillance to aid in the prevention of HAIs (13). The Institute of Medicine’s Report, To Err is Human, in 2000 helped to focus public attention on the problem of medical errors, including discussions on HAIs as preventable harms (14). Since that report, consumer advocacy groups, legislative bodies, and accreditation organizations have increasingly demanded public reporting of HAIs. These groups argued that heightened transparency of HAI rates would improve the quality of care largely by increasing competition to stimulate hospitals to reduce infections.

A hospital should have clear goals for doing surveillance. These goals must be reviewed and updated frequently to address new HAI risks in changing patient populations, such as the introduction of new high-risk medical interventions, changing pathogens and their resistance to antibiotics, and other emerging problems. The collection and analysis of surveillance data must be performed in conjunction with prevention strategies. It is vital to identify and state the objectives of surveillance before designing a surveillance program and starting it (15,16).