We conducted fourteen interviews. The professions of the participants in interviews were medical microbiologists, infectious disease specialists, intensivist, elderly care physician, hospital board director, clinical epidemiologist, and infectious disease pediatricians. The participants of the first group interview included three policy officers: one in hospital care, one in long-term care, and one in COVID-19. A policy officer and medical microbiologist took part in the second group interview (Supplementary material 2, Table 1.).
Operational infectious disease surveillance systems in hospitals
In general, the participants mostly discussed three large groups of operational infectious disease surveillance systems in hospitals : i) antimicrobial resistance (AMR) surveillance systems; ii) healthcare-associated infection surveillance systems; and iii) severe acute respiratory infections (SARI) surveillance systems. Antimicrobial resistance surveillance systems were often described by participants in relation to outbreak detection. The participants described healthcare-associated infection surveillance systems, such as postoperative wound and line infections, more frequently in relation to ‘infection prevention control’ and ‘quality-of-care’. In general, most participants perceived AMR surveillance and healthcare-associated infection surveillance (e.g., line infection and postoperative wound infection) [7] as useful and clinically relevant. The operational respiratory infections surveillance systems in hospitals discussed by the participants were characterized by their large diversity, ranging from (inter)personal observations to fully automated, (near) real-time laboratory surveillance of respiratory pathogens. The perceived value of a future SARI surveillance system in their hospital by hospital-based-participants is mixed. Some participants indicated that the value of a future SARI surveillance system might be regarded as less relevant by medical specialties other than medical microbiology or infectious disease. Other participants in the hospital setting underlined the relevance of a robust SARI surveillance system, particularly during outbreaks.
Barriers
Unclear stakeholder roles and responsibilities
A common theme apparent from the interviews was the unclear or passive role of hospitals in public health surveillance (Supplementary material 3, Table 2). Several medical specialists expressed that they do not feel that hospitals have a distinct role and/or responsibility in public health surveillance. Although most participants found it important to be notified if an infectious disease outbreak with an impact on hospital care is detected:
“If there is something unusual we need to know, I assume we will be told. There are plenty of channels where you can find that information. So if it is necessary, that it is there. Of course, it is also a matter of trust. I assume - I think most doctors have this confidence - that the RIVM will report issues if there is something noteworthy.” (participant 1)
Insight in the current role, responsibilities, and perceived urgency of having a robust respiratory surveillance in place in hospitals, was reflected by the one participant as follows:
“Every year we know that respiratory syncytial virus (RSV) will come again, and it is the same question every year: is it more? Are we testing more now? How bad is it now? […] Then I will go on the news and say: we are on the edge of being overwhelmed, but we will still manage […] How many admissions there really are and whether it is worse than last year we don’t know. With the Mycoplasma outbreak, the mega Mycoplasma outbreak that we had, we only found out about it, when [hospital capacity] was exceeded.” (participant 13)
Other participants expressed their willingness to actively participate in infectious disease surveillance with a broader public health scope in hospitals, but encountered problems to effectuate this. This was due to a lack of clear role description and a supportive legal framework.
“But it's things like that, and rules, that you run into. That there should be a vision about this: what is public health? And what is the role of hospitals in public health? And define that we in fact do have a role. Now it is so strictly separated that we have no role. And that means you can't do anything.” (participant 14)
Different Interpretation of General Data Protection Regulation
Dealing with different interpretations of the General Data Protection Regulation (GDPR) in relation to infectious disease surveillance in hospitals was regarded by many participants as a major challenge. Several participants mentioned the tendency of local privacy officers in hospitals to be conservative and nonuniform in their advice to medical specialists about sharing data for public health reasons. According to these participants this involves both sharing and linking patient- and/or laboratory data (e.g., sequence data) for public health surveillance. A participant described the experienced legal challenges by hospitals in the following example:
“GDPR, yes. The interpretation of that law is also very dependent on the lawyer who looks at it or the institute where you work. Of course, that’s all complicated. It [privacy issues] is maybe an even bigger threat, soon with AI, than the lack of support. We do monitor and share data on infectious diseases, but it has now gone so far that, for example, for healthcare evaluation, where the law simply states that this is allowed, that some lawyers still say: “don’t do it.” That’s an issue.” (participant 13)
In addition, there also seems to be a lack of knowledge or expertise in hospitals on what is allowed under the GDPR regarding data sharing for public health in case of infectious disease outbreak, as one participant explained:
“[…] To what extent are you allowed to exchange data according to the GDPR? So far no one can tell me that, except, “[phew], very difficult” and “I don’t know if it’s allowed”.” (participant 4)
Insufficient resources and capacity
An important barrier in infectious disease surveillance in hospitals is related to insufficient information and communications technology (ICT) capacity:
“So, more people in the team, or more ICT people in such a team are needed, […] That is really the bottleneck often when things don’t get off the ground. And that applies to me with my team, but I also think that all other parties that work with surveillance data, and automate it or generate overviews, simply [rely] on ICT capacity.” (participant 2).
According to several participants, ICT personnel are needed who also have a good understanding of the medical issues at hand. Ideally, they could assist medical staff in translating problems encountered in daily clinical care into ICT solutions. In the setting of limited ICT capacity and funding in many hospitals, prioritization of projects by decision-makers in hospitals becomes inevitable. Top-down prioritization within a hospital of infectious disease surveillance would then be beneficial according to some participants. A participant explains why an operational SARI surveillance system has not been established in their hospital yet:
“But also the priorities and workload in the ICT department mean that, I think, it has not yet been successful. So that’s workload, but also prioritization. If it was considered important enough, I think it might have been possible sooner.” (participant 6)
Facilitators
Clinically relevant and actionable data
A prominent theme regarding challenges in infectious disease surveillance in hospitals was related to clinical relevance of these hospital surveillance activities (Supplementary material 3, Table 2). Willingness to participate in infectious disease surveillance seemed related to whether the collected data was seen as clinically relevant and actionable enough for patient care to have added value for hospitals, which was seen as having direct consequences for medical treatment and/or medical policy in hospitalized patients. In this context, many participants expressed that infectious disease surveillance in hospitals becomes worthwhile if it improves patient quality of care and/or facilitates healthcare innovation. The positive returns of establishing infectious disease surveillance in hospitals has become increasingly clear to participants in recent years, such as regional AMR surveillance in the following example:
“Because you continuously do surveillance, we can act very quickly when it comes to infection prevention, and the lines of communication are also extremely short. I do that for this hospital, but my colleagues do it for the other hospital and we can all view those results. As a result, there are few intermediate links.” (participant 4)
In the context of a demanding hospital setting with a high administrative burden and staff shortages, it was also regarded essential to have a critical attitude about data requests by external stakeholders for infectious disease surveillance in hospitals in general, as was described by a participant:
“So, with every data source you ask for, I think you have to ask yourself: do I really need it? But also: where can you find these [data]? Is there already a standardization for this? And if not, then you really have to ask yourself whether that is something you should want to collect on a large scale in this phase, […]” (participant 12)
Mutually beneficial collaboration
One of the most important facilitators for establishing robust infectious disease surveillance in hospitals appeared to be mutually beneficial collaboration with relevant stakeholders. For instance, a participant described the close collaboration between a large academic hospital and the regional municipal health service within the Amsterdam Regional Genomic epidemiology and Outbreak Surveillance (ARGOS) consortium as illustrative of the advantages of sharing surveillance data and expertise, which could lead to direct action on the regional or local level. Other long-term collaborations that have intensified between regional microbiology laboratories and hospitals since the COVID-19 pandemic are illustrated by one of the participants as follows, regarding respiratory pathogens, such as influenza and SARS-CoV-2:
“[…] And from this a regional assembly originated in which all medical microbiologists and infection prevention experts are represented, and more and more regional policy decisions are being made. So, the great thing about that is: you share information, you share policy, and you also share in decisions, and I think that is very powerful and very nice that it has come about that way. That is also getting better and better.” (participant 9)
Sufficient support
A sufficient degree of support was described as valuable for facilitating robust and sustainable infectious disease surveillance in hospitals. This support was required on multiple levels, ranging from supportive legislation and expertise, a blueprint for implementing hospital surveillance, sufficient funding for diagnostics with a public health aim, to prioritization by both the medical staff and the medical board. With regard to the preferred support, several participants noted that mandatory infectious disease in hospitals, excluding the already notifiable diseases, is not regarded as useful, but a (legal) framework defining roles and responsibilities is.
Recommendations
The participants described strategies on how the most important challenges could be faced to establish or maintain robust infectious disease surveillance in hospitals, and on how to create added value from the hospital perspective.
Establish roles and responsibilities of stakeholders
A common notion was that the objectives, roles, and responsibilities in infectious disease surveillance in hospitals that have a broader public health scope must be clarified to create a shared vision. A first step that a participant suggested is to have open discussions about it with the most relevant stakeholders in hospital surveillance with a public health scope from multiple levels:
“[…] So perhaps, the solution is to look at this in a more nuanced way. What are the objectives of those types of surveillance, and can we simply explain it more clearly to each other and have a dialogue about it?” (participant 11)
In addition, several participants recommend that guidance from the Dutch Ministry of Health is also required to establish the (legal) framework for achieving sustainable infectious disease surveillance in hospitals.
“Frameworks. Look, you just have to indicate that there are also a number of stakeholders who have to find solutions together within certain frameworks. And those frameworks must be set. All from the same money, I always think. Not an easy process, but I think [it is] one that needs to be managed if you want to get out of this. Certainly, also for the future.” (participant 11)
Ensure actionable data with clinical relevance for hospital patient care
In general, it was emphasized to focus on obtaining actionable surveillance data from the hospital perspective, i.e., with impact on patient clinical care to ensure the sustainability of infectious disease surveillance in hospitals. The most often cited key attributes of these hospital surveillance systems were ‘timeliness’ and ‘flexibility.’ According to participants, the required timeliness differs for specific infectious disease syndromes or pathogens under surveillance, ranging from (near) real-time to monthly to quarterly to half-yearly. Additionally, it is dependent on the surveillance objective set by the hospital and/or the current epidemiological situation. In general, the value of sufficient timely hospital surveillance data was expressed as follows:
“It is of course information for action. So, you don't want to find out only a year later that there was a problem a year ago. So, timeliness is very important.” (participant 2)
The flexibility of surveillance systems was also regarded as an important attribute as the hospitals expressed a strong need to swiftly adapt to changing information needs. Adaptively upscaling or downscaling surveillance activities depending on a changing epidemiological situation was perceived as a requirement, especially in the setting of hospital outbreaks. In this context, a clear preference was expressed for routinely and continuously regional infectious disease surveillance data in addition to national infectious disease data:
“For the future it is super important to know - not only in the province, but maybe even in a part of the province - where is your problem? In which village or which...? And that you can really... As long as you can share that data with each other, you can really map it out fantastically and take specific measures.” (participant 9).
From the perspective of hospitals, having insight into infectious disease surveillance outputs on the regional level is regarded as highly beneficial, because it provides actionable data for their own catchment population. Especially, since regional transfers of patients occur frequently between hospitals in the Netherlands, insight into transmission dynamics on the regional level is regarded of the utmost importance. Participants elaborated on numerous initiatives (e.g., ARGOS, AMR Healthcare Networks) undertaken on the regional level by collaborating hospitals, microbiological laboratories and/or municipal health services to facilitate this need.
Benefit from the innovative qualities of hospitals
Several participants saw opportunities for establishing robust infectious disease surveillance in hospitals with a wider public health scope. One participant advised to benefit broadly from the innovative power of academic hospitals, ranging from utilizing their crosslinked networks, spin-off private companies, technological innovations, such as artificial intelligence, to their extensive expertise with complex patient groups:
“And I think you also should really use the innovative power of the University Medical Centers in the field of infectious diseases. That is where the University Medical Centers really have their added value. […]” (participant 11).
This innovative power of clinical microbiological laboratories was also underlined by another participant:
“If we want to have a system in which we can respond quickly to outbreaks, then you will need a system that embraces technological innovations. And that can actually be incorporated into the whole of how techniques, lab options, those developments are used in the microbiological world, so that they are immediately passed on throughout the chain.” (participant 14)