AN OVERVIEW ON INFECTION CONTROL DATA COLLECTION,

ANALYSIS

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DATA COLLECTION

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Healthcare Associated Infections (HAIs)

VAP, CLABSI, CAUTI & SSI.Hand Hygiene Alert OrganismsSharp Injuries

DATA PROCESSING

Data are collected , analyzed, and

transformed into useful information

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Presentation Outline

CDC Criteria of HAIsType & Methodology of Surveillance

workDesign an interpretive surveillance

reportData displayBenchmarkingBenchmarking requirements and

problems12/31/2013 ٤

What is Surveillance?

The ongoing, system collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with timely dissemination of these data to those who need to know.

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SURVEILLANCE, Why?

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Purposes of Surveillance-1

1. Reducing the infection ratewithin a hospital.

2. Establishing endemic (baseline) rates.

3. Identifying outbreaks.

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Purposes of Surveillance-2

4. Convincing medical staff.5. Defending malpractice claims.6. Comparing infection rates

among hospitals.

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Steps in SurveillanceDefinition of the event(s).Systematic collection of data.Preparation of Surveillance ReportAnalysis & interpretation.Benchmarking.Consuming the results for

improvement.

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Making Surveillance Work

Measurement

Knowledge

ActionAudit and evaluate practice

Stimulate changeWhat can be improved & how?

Active feedbackEngage leaders &clinicians

Training

Case definitionsAccurate data

Systematic collection Planning

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SURVEILLANCE FOR SURVEILLANCE FOR WHAT?WHAT?

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Device-Associated Infection

There is no minimum period of time that the device must be in place for the infection to be considered device-associated.

The date of the device-associated HAI event is either the date on which the first clinical evidence appeared or the date on which the specimen used to meet the HAI criteria was collected, whichever came first.

If the device-associated HAI develops within 48 hours of discharge from a location, then the HAI is associated with the discharging location.

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Central Line-Associated Bloodstream Infection (CLABSI) Event

A CLABSI is a primary bloodstream infection (BSI) in a patient who had a central line or umbilical catheter in place at the time of or within 48 hours before onset of the BSI.

Use CDC Criteria for Identification

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Ventilator-Associated Pneumonia (VAP) Event:

A VAP is pneumonia (PNEU) that is identified using a combination of radiologic, clinical and laboratory criteria and occurs in a patient who was intubatedand ventilated at the time of or within 48 hours before the onset of pneumonia.

Use CDC Criteria for Identification

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Catheter-Associated Urinary Tract Infection (CAUTI) Event:

CAUTI is defined as a symptomatic urinary tract infection (SUTI) or asymptomatic bacteremic UTI (ABUTI) in a patient who had an indwelling urinary catheter at the time of or within 48 hours before onset of the event.

Use CDC Criteria for Identification

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Dialysis Event (DE)

Hospitalization

In-unit IV antimicrobial starts

Positive blood culture

All patients with a positive blood culture even if they did not have an associated hospitalization or in-unit

IV antimicrobial start

All IV antimicrobial starts and is not limited to those with vancomycin or

for a vascular access problem

All hospitalizations that involved an overnight stay in a hospital and is

not limited to infections or situations

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PROCEDURE-ASSOCIATED MODULE

Surgical Site Infection (SSI) Event:

The SSI is an infection that occurs within 30 days (or within one year for an implant in the case of

organ/space SSI) after an operative procedure that involves the skin or subcutaneous tissue

(superficial incisional SSI), deep soft tissue (deep incisional SSI), or any other part of the body that is

opened or manipulated during the operative procedure (organ/space SSI).

Use CDC Criteria for Identification

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Post-Procedure Pneumonia (PPP) Event:

PPE is a pneumonia that is identified using a combination of radiological, clinical and laboratory criteria (such as VAP) and occurs after an inpatient operation but prior to discharge.

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Location/Period of Surveillance Events

CLABSI: Surveillance for CLABSI in at least one location (ICU, NICU, SCA, others) in the healthcare institution for at least one calendar month.

VAP: Surveillance for VAP in at least one location (ICU, NICU, SCA, others) in the healthcare institution for at least one calendar month

CAUTI: Surveillance for CAUTI performed in at least one location (ICU, SCA, others) in the healthcare institution for at least one calendar month

DE: Surveillance for DE for at least 6 months among chronic hemodialysis patients at an outpatient hemodialysis facility

SSI: Surveillance for at least one NHSN operative procedure performed in surgical patients in any inpatient/outpatient setting for at least one month

PPP: Surveillance for at least one NHSN operative procedure performed only in a surgical inpatient setting for at least one month

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The Patient Safety surveillance modules Active Patient-based Prospective, Priority-directed surveillance Of device/medication/procedure-associated

infection events Their corresponding denominator data by a

trained infection control professional (ICP).

SURVEILLANCE METHODOLOGY

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SURVEILLANCE METHODOLOGY

Active surveillancea) Trained personnel, mainly ICPs, are vigorously

look for HAIsb) Information is accumulated using a variety of data

sources within and beyond the nursing ward Passive surveillancea) Persons who do not have a primary surveillance

role, such as ward nurses or respiratory therapists, identify and report HAIs

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Patient-based and laboratory-based surveillance

1. Patient-based surveillancea) Count HAIs, assess risk factors, and monitor patient

care procedures and practices for adherence to infection control principles

b) Requires ward rounds and discussion with caregivers

2. Laboratory-based surveillancea) Detection is based solely on the findings of

laboratory studies of clinical Specimens.

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Prospective and Retrospective Surveillance

1. Prospective surveillancea) Monitor patients during their hospitalization

b) For SSIs, also monitor during the post-discharge period

2. Retrospective surveillancea) Identify infections via chart reviews

after patient discharge

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Priority-directed and comprehensive surveillance

1. Priority-directed surveillance (Targeted or focused surveillance)a) Objectives for surveillance are definedb) The focus is on specific events, processes, organisms, and/or patient populations

2. Comprehensive surveillance Universal Surveillancea) Continuous monitoring of all patients for all events and/or processes

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25

Risk-basedUnit-basedPathogen-basedProcedure-based

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Surveillance Collection Forms

L F

T im e en d ( c a th ete r s ec ur e d) :

M R #:

C h e ck if :

F em or a l

In t er na l J ugu lar

/ / D a te :

T yp e o f c a th e t er :

Tr ip le lu m e n In t ro d uc e r S w a n- G a n z

In se rt io n S it e :

S ub c lav ia n

O th er ( s pe c i fy ) :

P t /F a m i ly t e ac h ing do ne C on s e nt o bta ine d

P re - in s er tio n s kin p re p (c h e ck a n y u se d ) : A lc o ho l B e ta d ine (p ov id on e -io d in e) Ch lo r he x id ine O th er ( s pe c i fy ) :

De s c rib e th e c irc u m st an ce s u n de r w h ic h t h is lin e w as p lac e d : No n- e m e r ge nt E m e r ge n t ( l i fe - thr e a te n ing o r c o de s i t ua tion )

P l e as e f ile p ag e 2 in p at ie n t s ch a rt a n d re t u rn t o p f o rm t o t h e de s ig n a te d lo ca t io n i n th e IC U .

L ist a ll s it e s w h e re in s e rt io n w a s a t te m p t e d . O th er ( s pe c i fy ) :

: T im e s t ar t ( 1 s t ne ed le s tic k ) : :

Ho w m a n y d if f er en t ne e d le st ic k s d id t h e p a tie n t r ec eiv e ( n u m b e r o f s kin b re ak s ) ? 1 U n k no w n

T h e p ro v id e r in s e rt in g t h is lin e :

* If “ No ” , w as th is p ro c ed u re s u p e rv is e d b y s om e on e w ith le as t f iv e ( 5) c en t ra l lin e s e x p erie n c e? Y e s N o Did n ’ t a s k

Y e s N o

P le a s e u s e m il i ta ry t i m e (i .e . 1 :0 0 p m i s 1 3 :0 0 )

a. H a n d ed - o f f h is /h e r pa g e r b e fo r e th e p ro c e d u re ? Y e s N o b . W a s h ed h an d s im m e d ia te ly p r io r to p ro c ed u re ? Y e s N o *

D id n ’ t as k D id n ’ t as k D id n ’ t as k c. H a s p rev io u s ly p la c ed a t le a st f iv e ( 5) c en t ra l lin e s ?

De s c rib e th e lev e l o f t ra in in g o f t he p ers o n w h o a ct u a ll y in se rt e d t h e lin e ? M e dic a l S tu de nt In te r n ( P G Y -1 ) Re s ide nt (P G Y - 2+ ) F el low A tte nd in g

Ba rr ier p re c au t io n s ( ch e c k a n y u se d ) : S t er i le g lov es S te r ile g ow n M a s k S te r i le tow e ls F ul l bo dy dr a pe

S id e : Rig ht Le ft

2 3 4 5 6 +

F o llo w - u p C X R : O r de re d No t or de r e d ( s pe c i fy r e as o n ): CX R f in d in g s (c h e ck a ll t h a t a p p ly) :

No p ne u m o th or a x P n eu m ot ho r ax (d es c r ibe a c tio n t a k en ): C at he te r in g oo d po s i t io n C a the te r p os i tio n ad ju s te d ( de s c r ibe ) :

T yp e o f d re s sin g : B io - oc c lus iv e G a uz e O th er ( s pe c i fy ) :

P a t ien t to le ra t ed t he p roc e d u re w e ll? Y e s No

W a s t h e st e r ile f ie ld m ain t a in e d t h ro u g h ou t th e e n t ire p ro c ed u re? Y e s N o

Co m p lic a tio n s? No ne O th er ( d es c rib e) :

Dr es s in g a p p lie d b y : Nu r s e P r o c e dur a lis t O th er ( s pe c i fy ) :

N u r s i n g C h e c k l i s t: C e n tr a l V e n o u s C a t he te r I n s e r ti o n

V a n d e r b i l t U n i v e rs ity M e d ic a l C en te r

R IJ L IJ RS C L S C RF

G uid ew ir e e x c h an ge

P la c e m e nt un s uc c e s s fu l

MC 2 7 0 5 (R e v . 0 6 /0 4 )

NO T E : P le a s e u s e e i th er b lac k o r b lue in k to c om ple te th is f o rm .

C o m m e n ts :

V as c a th

S ig n at u re : _ __ __ _ __ __ __ _ __ __ __ _ __ __ __ _ __ __ _ __ __ __ _ __ __ __ _ D a t e : _ _ __ __ _ __ __ _ __ __ _

In d ic at io n s fo r u se : P r es s or s H e m o dy na m ic m o ni t. F lu id s /b lo od pr o du c ts F r e qu en t la b dr aw s

P r e -e x is tin g in fe c tio n

N u r s e P ra c ti tio ne r

D ou ble lum e n

at V an d e r b il t

M o n ro e C a re ll J r. O R

C C U M IC U S I CU B I CU P C C U NI C U

N S I C U TI C U O the r

L F

T ime en d ( ca th ete r sec ur e d) :

MR #:

C h e ck if :

F em or a l

Int er na l J ugu lar

/ / D a te :

T yp e o f c a th e t er :

Tr ip le lu me n Int ro d uce r Sw a n- G a n z

In se rt io n S it e :

Sub c lav ia n

O th er ( s pe c ify ) :

P t /F a mily t e ach ing do ne C on se nt o bta ine d

Pre - in s er tio n s kin p re p (c h e ck a n y u se d ) : Alco ho l B e ta dine (p ov id on e -io din e) Ch lo r he x id ine O th er ( s pe c ify ) :

De s c rib e th e c irc u m st an ce s u n de r w h ic h t h is lin e w as p lac e d : No n- e me r ge nt Eme r ge n t ( l i fe - thr e a te ning o r co de s i t ua tion )

Pl e as e f ile p ag e 2 in p at ie n t s ch a rt a n d re t u rn t o p f o rm t o t h e de s ig n a te d lo ca t io n i n th e IC U .

L ist all sit e s w h e re in s e rt io n w a s a t te m p t e d . O th er ( s pe c ify ) :

: T im e s t ar t ( 1 s t ne ed le s tick ) : :

Ho w m a n y d if f er en t ne e d le st ic k s d id t h e p a tie n t r ec eiv e ( n u m b e r o f s kin b re ak s ) ? 1 U n kno w n

T h e p ro v id e r in s e rt in g t h is lin e :

* If “No ” , w as th is p ro c ed u re s u p e rv is e d b y s om e on e w ith le as t f iv e ( 5) c en t ra l lin e s e x p erie n c e? Ye s N o Did n’t a sk

Y e s N o

P le a s e u s e m il i ta ry tim e (i .e . 1 :0 0 p m i s 1 3 :0 0 )

a. H a n d ed - o f f h is /h e r pa g e r b e fo r e th e p ro c e d u re ? Y e s N o b . W a s h ed h an d s im m e d ia te ly p rio r to p ro c ed u re ? Y e s N o *

D id n’t as k D id n’t as k D id n’t as k c. H a s p rev io u s ly p la c ed a t le a st f iv e ( 5) c en t ra l lin e s ?

De s c rib e th e lev e l o f t ra in in g o f t he p ers o n w h o a ct u a ll y in se rt e d t h e lin e ? Me dic al S tu de nt In te r n ( P G Y -1 ) Re s ide nt (P G Y - 2+ ) F el low A tte nd in g

Ba rr ier p re c au t io n s ( ch e c k a n y u se d ) : St er i le glov es S te r ile g ow n Ma sk S te r i le tow e ls F ul l bo dy dr a pe

S id e : Rig ht Le ft

2 3 4 5 6 +

F o llo w - u p C XR : O r de re d No t or de r e d ( s pe c ify r e aso n ): CX R f in d in g s (c h e ck a ll t h a t a p p ly) :

No p ne u mo th or a x Pn eu m ot ho r ax (d es c r ibe a c tio n t a ken ): C at he te r in g oo d po s it io n C a the te r p os itio n ad ju s te d ( de sc r ibe ) :

T yp e o f d re s sin g : Bio - occ lus ive G a uze O th er ( s pe c ify ) :

Pa t ien t to le ra t ed t he p roc e d u re w e ll? Ye s No

W a s t h e st e rile f ie ld m ain t a in e d t h ro u g h ou t th e e n t ire p ro c ed u re? Y e s N o

Co m p lic a tio n s? No ne O th er ( d es c rib e) :

Dr es s in g a p p lie d b y : Nu r se Pr o ce dur a lis t O th er ( s pe c ify ) :

N u rs in g C h e c k l is t: C e n tr a l V e n o u s C a t he te r In s e rtio n

Va n d e r b i l t U n iv e rs ity M e d ic al C en te r

R IJ L IJ RS C L SC RF

G uid ew ir e e xch an ge

P la ce me nt un suc ce ss ful

MC 2 7 0 5 (R e v . 0 6 /0 4 )

NO T E: P le a se u se eith er blac k o r blue in k to c om ple te th is f o rm .

C o m me n ts :

Vas ca th

Sig n at u re : _ __ __ _ __ __ __ _ __ __ __ _ __ __ __ _ __ __ _ __ __ __ _ __ __ __ _ D a t e : _ _ __ __ _ __ __ _ __ __ _

In d ic at io n s fo r u se : P r ess or s H e mo dy na m ic m o nit. F luid s /b lo od pr o du c ts F r e qu en t la b dr aw s

P r e -e x is tin g in fe c tio n

N u r se P ra c ti tio ne r

D ou ble lum e n

at V an d e r b il t

M o n ro e C a rell J r. O R

C C U M IC U SI CU BI CU P C C U NI C U

N SI C U TI C U O the r

L F

T im e en d ( c a th ete r s ec ur e d) :

M R #:

C h e ck if :

F em or a l

In t er na l J ugu lar

/ / D a te :

T yp e o f c a th e t er :

Tr ip le lu m e n In t ro d uc e r S w a n- G a n z

In se rt io n S it e :

S ub c lav ia n

O th er ( s pe c i fy ) :

P t /F a m i ly t e ac h ing do ne C on s e nt o bta ine d

P re - in s er tio n s kin p re p (c h e ck a n y u se d ) : A lc o ho l B e ta d ine (p ov id on e -io d in e) Ch lo r he x id ine O th er ( s pe c i fy ) :

De s c rib e th e c irc u m st an ce s u n de r w h ic h t h is lin e w as p lac e d : No n- e m e r ge nt E m e r ge n t ( l i fe - thr e a te n ing o r c o de s i t ua tion )

P l e as e f ile p ag e 2 in p at ie n t s ch a rt a n d re t u rn t o p f o rm t o t h e de s ig n a te d lo ca t io n i n th e IC U .

L ist a ll s it e s w h e re in s e rt io n w a s a t te m p t e d . O th er ( s pe c i fy ) :

: T im e s t ar t ( 1 s t ne ed le s tic k ) : :

Ho w m a n y d if f er en t ne e d le st ic k s d id t h e p a tie n t r ec eiv e ( n u m b e r o f s kin b re ak s ) ? 1 U n k no w n

T h e p ro v id e r in s e rt in g t h is lin e :

* If “ No ” , w as th is p ro c ed u re s u p e rv is e d b y s om e on e w ith le as t f iv e ( 5) c en t ra l lin e s e x p erie n c e? Y e s N o Did n ’ t a s k

Y e s N o

P le a s e u s e m il i ta ry t i m e (i .e . 1 :0 0 p m i s 1 3 :0 0 )

a. H a n d ed - o f f h is /h e r pa g e r b e fo r e th e p ro c e d u re ? Y e s N o b . W a s h ed h an d s im m e d ia te ly p r io r to p ro c ed u re ? Y e s N o *

D id n ’ t as k D id n ’ t as k D id n ’ t as k c. H a s p rev io u s ly p la c ed a t le a st f iv e ( 5) c en t ra l lin e s ?

De s c rib e th e lev e l o f t ra in in g o f t he p ers o n w h o a ct u a ll y in se rt e d t h e lin e ? M e dic a l S tu de nt In te r n ( P G Y -1 ) Re s ide nt (P G Y - 2+ ) F el low A tte nd in g

Ba rr ier p re c au t io n s ( ch e c k a n y u se d ) : S t er i le g lov es S te r ile g ow n M a s k S te r i le tow e ls F ul l bo dy dr a pe

S id e : Rig ht Le ft

2 3 4 5 6 +

F o llo w - u p C X R : O r de re d No t or de r e d ( s pe c i fy r e as o n ): CX R f in d in g s (c h e ck a ll t h a t a p p ly) :

No p ne u m o th or a x P n eu m ot ho r ax (d es c r ibe a c tio n t a k en ): C at he te r in g oo d po s i t io n C a the te r p os i tio n ad ju s te d ( de s c r ibe ) :

T yp e o f d re s sin g : B io - oc c lus iv e G a uz e O th er ( s pe c i fy ) :

P a t ien t to le ra t ed t he p roc e d u re w e ll? Y e s No

W a s t h e st e r ile f ie ld m ain t a in e d t h ro u g h ou t th e e n t ire p ro c ed u re? Y e s N o

Co m p lic a tio n s? No ne O th er ( d es c rib e) :

Dr es s in g a p p lie d b y : Nu r s e P r o c e dur a lis t O th er ( s pe c i fy ) :

N u r s i n g C h e c k l i s t: C e n tr a l V e n o u s C a t he te r I n s e r ti o n

V a n d e r b i l t U n i v e rs ity M e d ic a l C en te r

R IJ L IJ RS C L S C RF

G uid ew ir e e x c h an ge

P la c e m e nt un s uc c e s s fu l

MC 2 7 0 5 (R e v . 0 6 /0 4 )

NO T E : P le a s e u s e e i th er b lac k o r b lue in k to c om ple te th is f o rm .

C o m m e n ts :

V as c a th

S ig n at u re : _ __ __ _ __ __ __ _ __ __ __ _ __ __ __ _ __ __ _ __ __ __ _ __ __ __ _ D a t e : _ _ __ __ _ __ __ _ __ __ _

In d ic at io n s fo r u se : P r es s or s H e m o dy na m ic m o ni t. F lu id s /b lo od pr o du c ts F r e qu en t la b dr aw s

P r e -e x is tin g in fe c tio n

N u r s e P ra c ti tio ne r

D ou ble lum e n

at V an d e r b il t

M o n ro e C a re ll J r. O R

C C U M IC U S I CU B I CU P C C U NI C U

N S I C U TI C U O the r

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SURVEILLANCE DATA ANALYSIS

1. Incidence rate: This rate is a measure of the frequency with which an event occurs in a population over a defined time period. The numerator is the number of new cases that occur during the defned time period, and the denominator is the population at risk.

2. Prevalence rate: This rate is the proportion of persons in a population who have a particular disease or condition (new and previously existing) at a specified point in time or over a specified period of time.

Note: Attack rate is a type of incidence rate used to measure the frequency of new cases of a disease or condition in a specifc population during a given (short) period of time and is expressed as a percentage.

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28

Incidence = new cases x constant (1000)population at risk

Prevalence = existing cases x constant(1000)population at risk

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Measures of Frequency:

1. Rate: an expression of the frequency with which an event occurs in a defined population; for example, the CLABSI incidence rate is 5.3 per 1,000 CL-days

2. Ratio: the value obtained by dividing one quantity by another; for example, the ratio of females to males is 2:1

3. Proportion: a type of ratio in which the values in the numerator are included in(i.e., are a subset of) the denominator; for example, 33% of the population is in risk category 1

SURVEILLANCE DATA ANALYSIS

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30

½ X 1,000

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31

Population at risk Patient days / residents days Device dayscentral line daysventilator daysFoley catheter days

Procedures performed

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32

HAIs cases-SSI, VAP, CLABSI, CAUTI.

Positive blood culturesPositive VREPositive MRSAPatients on vancomycin

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CLABSI Infection Rate = No. of HAIs associated with Central Line x 1000No. of Central Line days

Utilization Ratio of Central Line = No. of days of the Central Line usedTotal no. of patient days

Calculating Rates Calculating Rates

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CAUTI Infection Rate = No. of HAIs associated with Urinary Catheter 1000No. of urinary catheter days

Utilization Ratio of Urinary Catheter = No. of days of the Urinary CatheterTotal no. of patient days

Calculating RatesCalculating Rates

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VAP Infection Rate = No. of HAIs associated with ventilator x 1000No. of ventilator days

Utilization Ratio of Ventilator = No. of days of the catheter usedTotal no. of patient days

Calculating RatesCalculating Rates

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SSI Rate by Type of Operation = No. of SSI in a specific type of operation x 100Total no. of that operation

Calculating RatesCalculating Rates

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Surveillance Report

1.Define the event, population, setting and time period ( e.g. surgical site infections in patients undergoing coronary artery bypass graft in hospital A from January through December 2013

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Surveillance Report

2. State the criteria used for defining a case (CDC criteria)

3. Specify the number of cases or events identified and the number in population studied (e.g. 2 surgical site infections in 179 total hip replacement procedures performed)

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Surveillance Report

4. Explain the methodology used to identify cases (e.g., case reports from personnel and review of medical records and laboratory results.

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Surveillance Report

5. Identify the statistical methods and calculations used, when appropriate (e.g., SSI Rate in April = # patients with SSI after selected operations in April/ Total # of selected operations performed in April x 1000)

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Surveillance Report

6. State the purpose for conducting surveillance ( e.g., to reduce the rate of occurrence of an event).

7. Interpret the findings in a manner that is understandable to those who read the report.

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Surveillance Report

8. Describe any actions taken and recommendations made for prevention and control measures.

9. Identify the author and date of the report.

10. Identify the recipients of the report

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Design an Interpretive Surveillance Report

The report should be disseminated to those managers and healthcare providers in the organization who can use the findings to influence performance improvement activities.

Monthly Surveillance Report

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Data Display Tools

TablesBar ChartsHistogramsPie ChartsRun chartsStatistical Process Control Charts

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Graphic Analytical Analysis

Bar graph

Line graph

Pie graph

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Tables, Graphs, and Charts

Complete Title describing the contentsLimited informationLabels describe the contentMake it concise and easily readable If you use codes, abbreviations, or

symbols, use footnotes to explainMonthly Surveillance Statistics

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Why Analyze, Display and Report Data?

Tracking and Trending Trends/changes overtime Seasonal occurrences Outbreaks Sentinel events Benchmarking/ Comparison Compare to others Detects areas for improvement Use to improve performance

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BENCHMARKING

Benchmarking is the process of comparing oneself to others who are performing similar activities, so as to continuously improve.

The National Healthcare Safety Network (NHSN)in the US is the oldest and most widely used network for benchmarking.

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Requirement for Successful Benchmarking

Criteria for defining a case are standardized and up to date. The population and time period for the study are well defined. The surveillance methodology is standardized and consistently used

by all of the participants over time. Rates and ratios are calculated using the same numerators (number

of cases) and denominators (population at risk). All data collectors receive training on how to collect data and use a

standardized form. The facility and population that is compared is similar to the types of

facilities and populations in an aggregate database used for external comparison

NHSN Report 201012/31/2013 ٥١

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Teamwork and Effective Communication For Successive Surveillance Work

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