SmartSteward EYE™ Respiratory Virus and Resistant Organism Electronic Surveillance and Alert System for Skilled Nursing Facilities

SmartSteward EYE™, a product of SmartSteward, Inc., delivers real-time surveillance of respiratory virus-like events (RVLEs) and multi-drug resistant organisms (MDROs) in skilled nursing facilities (SNFs). The early warning system detects potential outbreaks of these agents, as well as prevalence, location mapping and incidence by month.

SmartSteward EYE™ provides an immediate solution for two critical issues in SNFs:

  1. The impending pandemic of SARS-CoV-2.
    There is an urgent need for tools to safeguard SNF residents. Estimated COVID-19 mortality in the U.S. SNF population is likely to exceed the 15-21% projected by the World Health Organization (WHO) and the Chinese CDC (for patients >80 years of age) due to extreme debility and age. Chinese CDC Report Feb 2020; WHO Feb 28 CoVID-19 Report.SNF residents live together in close proximity, eating and enjoying activities in common areas, placing them at the highest risk for the rapid dissemination of this virus. SNFs do not have systems to actively monitor for early detection of RVLEs like COVID-19 or influenza. Early detection of these agents allows SNFs to more quickly put control measures in place to mitigate potential outbreaks.
  2. The emergence of SNFs as reservoirs of MDRO.
    An equally grave development is the fact that SNFs serve as major multipliers in the MDRO epidemic. SNF MDRO colonization rates are between 15 and 60%, much higher than acute care hospitals. MDRO in LTC CID 2019; MDRO Transmission in LTC Curr Inf Dis Rpt 2017. It follows that any proposed plan for significant control of the MDRO pandemic would necessarily include a solution for SNFs. The unfortunate reality is that these facilities do not have trained personnel or resources to address the MDRO problem. Staff are often only vaguely aware of MDROs and facility administrators are frequently not aware of the extent of the problem in their building because true surveillance has not been required. SNFs do commonly receive annual antibiograms from their microbiology laboratory but these documents are viewed as a mere formality for inspections. Specific information about MDRO prevalence, incidence and/or location is not included in an antibiogram. The decades-old concept of the standard antibiogram is therefore not useful for defining and controlling MDROs. The critical first step to control MDROs is to recognize the problem so that appropriate control techniques such as decolonization, isolation and antibiotic stewardship can be instituted. Stewardship Effect on Resistance Review Lancet ID 2017; PROTECT Trial 2019

SmartSteward EYE™ features:

RVLE detection and reporting.
SmartSteward EYE™ extracts data from objective clinical measurements such as MDS assessments, vital signs and nurses notes; laboratory data; prescriptions; community respiratory virus activity and X-ray orders to detect events that are likely to be respiratory infections. The RVLE detection algorithm uses more than 20 data points available in the electronic health record (EHR) to score the likelihood of an individual having a respiratory virus infection. The algorithm attempts to score an event in the same manner as would an expert physician. Algorithms will be refined with machine learning techniques and as new information about COVID-19 becomes available.

The MDRO detector.
SmartSteward EYE™ MDRO tracker has been fully validated over a year of pilot operations and identifies with very high accuracy the following 9 agents of most concern:

  • MRSA, Methicillin-Resistant Staphylococcus aureus
  • VRE, Vancomycin-Resistant Enterococcus
  • ESBL, Extended Spectrum Beta-lactamase producing Enterobacterales
  • CRE, Carbapenem-Resistant Enterobacterales
  • CRAB, Carbapenem-Resistant Acinetobacter baumanii
  • CRP, Carbapenem-Resistant Pseudomonas aeruginosa
  • MDRO Pseudomonas aeruginosa
  • Candida auris
  • Clostridioides difficile

Most clinical laboratories do not routinely identify all these agents as MDROs of concern and the SNF must rely on manual tracking by the infection control personnel and the vigilance of bedside nurses or the physician to recognize the significance of these isolates.

Communication of findings.
SmartSteward EYE™ collects relevant information through integration and does not require any special effort or knowledge of SNF personnel. It is their responsibility to interpret the results and act upon them if indicated.

Both the RVLE data and the MDRO data are presented to key facility personnel by:

  • HIPAA compliant alerts via instant text message if urgent or daily email if less urgent.
  • Incidence reports that include special alerts when a potentially significant RVLE is detected, an MDRO is detected or an apparent cluster occurs.
  • Current and monthly prevalence reports of RVLE and individual MDRO presence.
  • Heat maps that display current location and location history.

Data can be sent to the health department or CDC agencies such as the NHSN after validation by the facility.

SmartSteward SMS

SmartSteward EYE™ 24/7 surveillance can immediately issue text or email alerts for urgent events such as a potential COVID-19 outbreak.

Tracking of MDROs over time allows for early detection of outbreaks, timely institution of control measures, and monitoring of the results of those control measures.

Outbreaks of respiratory viruses such as RSV, Metapneumovirus, Parainfluenza, etc. are common but difficult to detect as often the clinical diagnosis is heterogeneous. The physician may diagnose asthma in one patient while other patients are diagnosed as pneumonia or COPD exacerbation. Parsing these events can reveal outbreaks that warrant patient safety action in the debilitated SNF resident population.

C.diff (Clostridioides difficile) colitis kills ~23,000 in the U.S. every year. Outbreaks can be controlled with antibiotic stewardship, isolation and cleaning procedures.

SmartSteward EYE™ provides an indispensable motion heat map to help control an outbreak of MDRO or RVLE.

SmartSteward EYE™ is scalable because it simply requires an interface with the facility EHR to be implemented No change in facility culture or protocols is required.

SmartSteward, Inc. has been focused on SNF infection control (IC) and antibiotic stewardship (AS) for nearly two years and has completed a one-year pilot of a comprehensive IC and AS package that includes nursing/physician messaging and antibiotic decision support designed to suppress MDRO by manipulating antibiotic usage patterns. Measurable outcomes have been excellent.

Results from the Comprehensive SmartSteward system.


Pilot data. Using decision support and prescriber feedback antibiotic exposure to the facility was decreased by 64% over baseline.

Excess antibiotic use is associated with worse outcomes in SNFs.
Variability of Antibiotic Use in SNF & Outcomes JAMA IM 2015


Using physician and nurse feedback, antibiotic use for asymptomatic bacteriuria was markedly decreased.


The HAI (Hospital Acquired Infection Rate per 1000 pt-days) was decreased dramatically with the January installation of SmartSteward by standardizing infection definitions to McGeer criteria. Later reductions were due to the decreased antibiotic exposure and the Hawthorne Effect (the act of monitoring reduces infections as employees understand they are being monitored).