title: Detecting borderline infection in an automated monitoring system for healthcare-associated infection using fuzzy logic.
abstract: Many electronic infection detection systems employ dichotomous classification methods, classifying patient data as pathological or normal with respect to one or several types of infection. An electronic monitoring and surveillance system for healthcare-associated infections (HAIs) known as Moni-ICU is being operated at the intensive care units (ICUs) of the Vienna General Hospital (VGH) in Austria. Instead of classifying patient data as pathological or normal, Moni-ICU introduces a third borderline class. Patient data classified as borderline with respect to an infection-related clinical concept or HAI surveillance definition signify that the data nearly or partly fulfill the definition for the respective concept or HAI, and are therefore neither fully pathological nor fully normal.
  
  
  
  Using fuzzy sets and propositional fuzzy rules, we calculated how frequently patient data are classified as normal, borderline, or pathological with respect to infection-related clinical concepts and HAI definitions. In dichotomous classification methods, borderline classification results would be confounded by normal. Therefore, we also assessed whether the constructed fuzzy sets and rules employed by Moni-ICU classified patient data too often or too infrequently as borderline instead of normal.
  
  
  
  Electronic surveillance data were collected from adult patients (aged 18 years or older) at ten ICUs of the VGH. All adult patients admitted to these ICUs over a two-year period were reviewed. In all 5099 patient stays (4120 patients) comprising 49,394 patient days were evaluated. For classification, a part of Moni-ICU's knowledge base comprising fuzzy sets and rules for ten infection-related clinical concepts and four top-level HAI definitions was employed. Fuzzy sets were used for the classification of concepts directly related to patient data; fuzzy rules were employed for the classification of more abstract clinical concepts, and for top-level HAI surveillance definitions. Data for each clinical concept and HAI definition were classified as either normal, borderline, or pathological. For the assessment of fuzzy sets and rules, we compared how often a borderline value for a fuzzy set or rule would result in a borderline value versus a normal value for its associated HAI definition(s). The statistical significance of these comparisons was expressed in p-values calculated with Fisher's exact test.
  
  
  
  The results showed that, for clinical concepts represented by fuzzy sets, 1-17% of the data were classified as borderline. The number was substantially higher (20-81%) for fuzzy rules representing more abstract clinical concepts. A small body of data were found to be in the borderline range for the four top-level HAI definitions (0.02-2.35%). Seven of ten fuzzy sets and rules were associated significantly more often with borderline values than with normal values for their respective HAI definition(s) (p<0.001).
  
  
  
  The study showed that Moni-ICU was effective in classifying patient data as borderline for infection-related concepts and top-level HAI surveillance definitions.
authors.affiliation: Section for Artificial Intelligence and Decision Support, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, A-1090 Vienna, Austria. Electronic address: jeroen.debruin@meduniwien.ac.at.
authors.forename: Jeroen S
authors.initials: JS
authors.lastname: de Bruin
authors.affiliation: Section for Artificial Intelligence and Decision Support, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, A-1090 Vienna, Austria; Medexter Healthcare GmbH, Borschkegasse 7/5, A-1090 Vienna, Austria.
authors.forename: Klaus-Peter
authors.initials: KP
authors.lastname: Adlassnig
authors.affiliation: VAMED-KMB Hospital Management and Operation GmbH, Spitalgasse 23, A-1090 Vienna, Austria.
authors.forename: Alexander
authors.initials: A
authors.lastname: Blacky
authors.affiliation: University Clinic for Hospital Hygiene and Infection Control, Medical University of Vienna and Vienna General Hospital, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
authors.forename: Walter
authors.initials: W
authors.lastname: Koller
mesh_terms: D000328:Adult; D001331:Automation; D002984:Clinical Laboratory Information Systems; D003428:Cross Infection; D057225:Data Mining; D003936:Diagnosis, Computer-Assisted; D057286:Electronic Health Records; D017143:Fuzzy Logic; D006801:Humans; D007362:Intensive Care Units
keywords: Automated monitoring and surveillance systems; Fuzzy logic; Healthcare-associated infections; Infection control; Intensive care units