BEST PRACTICES FOR SURGICAL SITE INFECTION (SSI)

Janet Sullivan RN, BSN, CIC

November 20, 2013

Discuss the impact of SSIs on patient safety

and the cost of healthcare

Describe the CDC’s surveillance methodology

for SSIs.

Apply the definitions of infection used for SSI

surveillance, including criteria for superficial,

deep, and organ/space infections

Use the surveillance data to generate infection

rates and reports that can be integrated into

your ASC’s QAPI program

LEARNING OBJECTIVES

This webinar will review key concepts of the

SSI option in NHSN

In addition, participants will become familiar

with the page content of NHSN’s

“Surveillance for Surgical Site Infection (SSI)

Events

http://www.cdc.gov/nhsn/acute-care-

hospital/ssi/index.html

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IS YOUR FACILITY PARTICIPATING IN NHSN’S PATIENT SAFETY, PROCEDURE-ASSOCIATED MODULE: SURGICAL SITE SURVEILLANCE?

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Discuss the impact of SSIs on patient

safety and the cost of healthcare Describe the CDC’s surveillance methodology for SSIs

Apply the definitions of infection used for SSI surveillance,

including criteria for superficial, deep, and organ/space

infections

Use the surveillance data to generate infection rates and

reports that can be integrated into your ASC’s QAPI

program

Learning Objectives

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Despite advances in infection prevention practices, SSI

remains a substantial cost of morbidity and mortality in the

inpatient setting

SSIs are the most common healthcare associated infection,

accounting for 31% of all HAIs among hospitalized patients

Account for 42% of the extra dollar charges attributed to

HAIs ($5-10 billion annually)

Current data related to surgical site infections (SSIs) and

other HAIs come primarily from hospitals, which have an

established infrastructure with personnel dedicated to

infection control and prevention and HAI surveillance

Surgical Site Infection-Financial Cost

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The patient experience…. • The pain and ‘stinking’ leaking wounds lasted

for weeks and months leaving patients feeling in ‘utter despair’ and ‘wanting to die’

• The psychological stress on patients and their families was immense, coping with the infection as well as the financial costs of being off work

Surgical Site Infection-Human Cost

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Tanner J, et al. Patients’ experience of surgical site infection. Journal of Infection Prevention. July 2012;13(4).

ASC SSI reporting

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National estimates regarding the number of

HAIs originating in ASCs are not available

and little is known about infection control

and prevention practices in these settings

Massachusetts, Nevada, New Hampshire

and Texas, have state mandates for SSI

reporting in ASCs; the aforementioned

states are using NHSN to report SSIs in ASCs

Evaluation of these states’ experiences will

be needed to determine how the system

might be tailored to better fit the needs of

outpatient settings

Currently, all Medicare-certified ASCs are expected, as part of the CMS CfCs (Conditions for Coverage), to have a system in place to actively identify infections that may have been related to procedures performed in the ASC. To support a consistent approach to HAI surveillance in ASCs, by December 31, 2013, HHS, with stakeholder input, will perform the following

1. Identify a set of ASC procedures for which SSI definitions and methods should be developed; and,

2. Establish a multi-year plan and phased approach to support their routine surveillance

The tentative release date for NHSN’s new Outpatient Procedure

component for the

reporting of surgical procedures and subsequent SSIs by ASCs and

hospital

outpatient departments has been revised to July 2015

Updates will be provided via quarterly newsletter as they become

available

http://www.cdc.gov/nhsn/newsletters.html

ASC SSI reporting

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http://www.dhhs.nh.gov/dphs/cdcs/hai/documents/hai2012-asc.pdf

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Discuss the impact of SSIs on patient safety and the

cost of healthcare

Describe the CDC’s surveillance

methodology for SSIs Apply the definitions of infection used for SSI

surveillance, including criteria for superficial, deep,

and organ/space infections

Use the surveillance data to generate infection rates

and reports that can be integrated into your ASC’s

QAPI program

Learning Objectives

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Step One: SSI surveillance

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A. Decide which procedures will be monitored and record them in a Monthly Reporting Plan

- CMS, State or Corporate required - The highest volume - Ones that you feel might carry a higher risk - Surgeon request

B. Is it considered a NHSN surgical procedure - require 30 day or 90 day post op surveillance - this is a change from the 2012 SSI criteria—no longer

follow implant surgery for one year. Only 30 day or 90 day

surveillance is required for 2013 procedures C. Complete denominator form(s) for each procedure monitored - Spreadsheet with data elements

Examples

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1. Your ASC center performs a high volume of laparoscopic inguinal

hernia repairs and

you decide you’d like to perform surveillance on this procedure group

2. A surgeon has noticed a spike in infections related to percutaneous

endoscopic gastrostomy tubes being inserted at your ASC facility. He

has requested

these be monitored for 6 months

First thing you need to know is the ICD-9 codes assigned to each

procedure. This determines which NHSN procedure code category it

falls into and guides the time period for post op SSI surveillance

B. How do I know which “category” the procedure falls into?

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Go to: http://www.cdc.gov/nhsn/acute-care-hospital/ssi/index.html

Scroll down to ICD-CM Procedure Code Mapping to NHSN Operative Procedure Categories

NHSN 2014 changes

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Transition from ICD-9-CM codes to ICD-10-PCS and

CPT codes

• Previously: migrating to exclusive use of CPT

codes by

January 2015

• Current: Allow BOTH ICD-10-PCS and CPT

codes for 2015

SSI reporting

• Dual mapping to operative procedure

categories for both code

set by mid-to-late 2014

B. How do I know how long to follow the procedure for

development of SSI?

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Go to: http://www.cdc.gov/nhsn/acute-care-hospital/ssi/index.html

Scroll down to Protocols: SSI event

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Denominator list

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Knowledge check

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Columbia River ASC has chosen to monitor knee arthroscopy chondroplasty (ICD-9 80.96 –OTH code) procedures during the month of June. 40 procedures are performed in June and 2 of these procedures result in SSIs. If entering the denominators on an Excel spreadsheet, how many lines will be occupied with patient information, procedures, and additional information? Choose one: a. 40 b. 42 c. 2

a. 40

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Step Two: SSI surveillance

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Decide on a surveillance method that will be used to capture potential SSIs

• Surgeons: Self report, mailed/faxed form • Patients: Phone calls or mail survey • Micro data: Wound cultures • Pharmacy: Antibiotics prescribed • Coding data: Office visit

Method Potential Advantages Potential Disadvantages Routine wound examination by trained professional

High sensitivity and specificity Labor intensive, prospective only

Outpatient chart review by trained professionals

High sensitivity and specificity Labor intensive

Surgeon Reporting Self Initiated High specificity, resource efficient Poor sensitivity Mail Survey Acceptable specificity, relatively

resource efficient Suboptimal sensitivity

Patient reporting Mail Survey Relatively resource efficient Unreliable sensitivity and

specificity Telephone Survey Good public relations Labor intensive, unreliable

sensitivity and specificity Microbiological data Relatively resource efficient, may

“flag” potential SSIs Unreliable sensitivity and specificity.

Claims data algorithm incorporating discharge diagnosis codes, procedure codes, pharmacological Rx date*

Electronically available, increased sensitivity and positive predictive value

Changes in coding practices with changes in pay for performance practices, applicable in a limited, managed care type setting where patients follow up in the same system that they received operative treatment; poor sensitivity

Clinic notes text searching ** Can be individualized to discipline No widely accepted benchmark for f/u rates, definitions would need to be standardized by discipline, rate of f/u influenced by multiple factors, attrition bias (f/u response not representative of the original population)

Step two: Methods to identify potential SSIs TABLE 9. Summary of Literature Review of Surgical Site Infection Surveillance Practices Conducted in Non-Acute Care Settings*

Key References/Notes: Manian FA. Surveillance of in alternative settings: Exploring the current options. Am J Infect Control 1997;25:102-5. *Yokoe DS, et al. Enhanced identification of postoperative infections among inpatients. Emerging Infectious Diseases 2004;10:1924-1930. **Michelson J. Improved detection of orthopedic surgical site infections occurring in outpatients. Clin Orthop Rel Research 2005; 433:218-224.

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Sample: Surgeon Surveillance Form

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Discuss the impact of SSIs on patient safety and the cost of

healthcare.

Describe the CDC’s surveillance methodology for SSIs

Apply the definitions of infection used

for SSI surveillance, including criteria

for superficial, deep, and organ/space

infections Use the surveillance data to generate infection rates and

reports that can be integrated into your ASC’s QAPI program

SSI Learning Objectives

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Surgical Site Infection (SSI)

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Surgical Site Infection (SSI)

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Surgical Site Infection (SSI)

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Surgical Site Infection (SSI)

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Which of these is/are considered primary closure?

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Answer: A & B.

Per NHSN if any part of the

wound is approximated, it is considered a

primary closure

A

B

Surgical Site Infection (SSI)

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Surgical Site Infection (SSI)

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Surveillance period for Deep Incisional or Organ Space SSI http://nhsn.cdc.gov/nhsntraining/courses/C08/page3934.html

Surgical Site Infection (SSI)

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For any/all NHSN procedures:

In the first 30 days post op,

monitor for superficial, deep, or

organ/space

For a selected group of NHSN

Group of NHSN operative

procedures: up to 90 days post op,

monitor for deep incisional or

organ/space

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Surgical Site Infection (SSI)

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Surgical Site Infection (SSI)

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Surgical Site Infection (SSI)

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Knowledge check

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You are doing surveillance on breast expander

exchange to a silicone implant.

You find that the ICD 9 code for this procedure is 85.96

– BRST code.

Mrs. Doe underwent this procedure on July 15. She

returned to the surgeon’s office on September 1 for a

routine check.

The surgeon recorded “purulent drainage from the

superficial surgical site”.

Does this meet criterion for superficial incisional SSI? No—doesn’t occur within 30

days post op

Is 30 day or 90 day surveillance performed on

this procedure?

Surgical Site Infection (SSI)

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Surgical Site Infection (SSI)

Knowledge check

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You are doing surveillance on cervical laminectomy

procedures with 03.09

ICD 9 code – LAM code.

Mr. Doe underwent this procedure on July 18. He returned to

the surgeon’s office on September 15 with purulent wound

drainage, the superficial wound was opened and culture was

taken. He was admitted to the hospital from the surgeon’s

office and underwent an exploration. They opened the incision

with several retractors and cut the fascia to expose the dura.

No frank purulence was found in the wound. Deep wound

cultures were taken. The thecal sac was inspected with no

evidence of CSF leak. All the wound cultures were positive for

MSSA.

Does this meet criteria for superficial incisional SSI?

No-outside the 30 day window for surveillance

Does this meet criteria for deep incisional SSI?

No-surveillance for this procedure past 30 days post

op is not performed

Surgical Site Infection (SSI)

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http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf

Surgical Site Infection (SSI)

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Surgical Site Infection (SSI)

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http://www.cdc.gov/nhsn/ambulatory-

surgery/ssi/index.html

Knowledge check

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You are doing surveillance on shoulder arthroscopic repairs.

(ICD 9 is 81.83- OTH code)

Mrs. Post underwent this procedure on 9/24 for repair of the labrum

(tennis player). She returned to the surgeon’s office on 10/25 with

concerns of serosanguineous drainage from incisional site

accompanied with joint pain and limitation of movement which began

on 10/23.

The surgeon cleans the site with sterile gauze and sterile normal

saline, aseptically obtains a culture as he expresses more fluid from

wound, and then aspirates synovial fluid for analysis and culture. The

incisional and synovial cultures are positive for S. epidermis.

Microscopic exam of the synovial fluid revealed a WBC count of

15,000 with neutrophil at 77%, very low glucose and high protein

level. Surgeon diagnosis patient with a surgical site infection.

Does this meet criteria for superficial incisional SSI?

Does this meet criteria for Organ/Space infection?

Yes—organism isolated from aseptically obtained

culture of fluid

Yes—meets criteria b. of organ/space and #1

of JNT criteria

Is 30 day or 90 day surveillance performed on this

procedure?

Which one would you report it as?

Organ Space-JNT Always report the deepest level

Same patient-little different info

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Mrs. Post underwent this procedure on September 24th

for repair of the labrum. She returned to the surgeon’s

office on October 25 with concerns of serosanguineous

drainage from incisional site accompanied with joint

pain and limitation of movement which began on

October 23rd.

The surgeon cleans the site with sterile gauze and

sterile normal saline, aseptically obtains a culture as he

expresses more fluid from wound, and then aspirates

synovial fluid for analysis and culture. The incisional

and synovial fluid cultures were negative. Synovial fluid

was purulent and microscopic exam of that revealed a

WBC count of 15,000 with neutrophil at 77%, very low

glucose and high protein level

Does this meet criteria for

Organ/Space infection?

Yes-meets c. of Organ/Space

Meets #2 and # 3c of JNT

SSI scenario

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Mr. Rottman underwent a laparoscopic left inguinal

hernia with mesh via total extraperitoneal (TEP)

approach on October 28th. The ICD-9 code was 17.12

– HER code. He returned to the surgeon’s office on

November 30th with increasing pain/discomfort in left

groin site. The surgeon re-explored the site for fear of

strangulated recurrent left inguinal hernia. “An incision

was made extending from the pubic tubercle just to

beyond the deep inguinal ring and revealed an infected

pre-peritoneal mesh that was submerged in a lake of

pus”. Culture of the pus revealed no growth.

Surgeon diagnosed patient with surgical site infection. Does this meet criteria for superficial SSI?

No-past 30 days post op and below superficial layers anyway

Does this meet criteria for deep incisional SSI?

Yes-occurs within 90 days post op, involves the deep tissues and includes

a. purulent drainage from the deep incision (DIP)

SSI scenario

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Mrs. Sullivan underwent a open reduction and internal

fixation of right displaced radius fracture on October 1

(fx due to fall). The ICD-9 code was 79.32 – FX code.

She returned to the surgeon’s office on October 15th

with increasing redness, pain, heat and scant

serosanguineous drainage at her surgical incision. No

cultures are done. The surgeon diagnosis the patient

with “cellulitis” and prescribes Keflex for two weeks.

Does this meet criteria for SSI? No

The patient returns to the office in two days (Oct 17th)

with worsening redness, increasing pain and superficial

dehiscence of wound. No cultures are done. The

surgeon begins local wound care (betadine soaked

gauze BID) and documents “poor wound healing”. He

changes her antibiotic therapy to Bactrim.

Does this meet criteria

for SSI?

No

The patient returns in three weeks later (Nov 17th) with

fever 38.60C and purulence in her wound. The surgeon

explores the wound (in the OR) and takes “deep

wound” cultures which return positive for MRSA

Does this meet criteria

for SSI? Which category? Deep incisional

primary (DIP)

SSI Numerator Collection Forms

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SSI Collection Form Alternative (if not reporting in NHSN)

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Discuss the impact of SSIs on patient safety and the

cost of healthcare

Describe the CDC’s surveillance methodology for SSIs.

Apply the definitions of infection used for SSI

surveillance, including criteria for superficial, deep,

and organ/space infections

Use the surveillance data to generate infection rates

and reports that can be integrated into your ASC’s

QAPI program

SSI Learning Objectives

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Calculating Non-stratified SSI rates: #infections/#procedures performed X 100

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Display of SSI organisms

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0

0.2

0.4

0.6

0.8

1

1.2

ASC IP notified of an “increase” in laminectomy

infections.

Timeline of Events: Craniotomy Surgical Site Infection Reduction Project

IP performed retrospective surveillance for lami infections and conducted observations in the operating room during lami procedures. At it’s height, lami

infections exceeded 4%.

Periop: promote pre-op showers, am pre-op CHG cloth wipe, eliminate multi-use patient items, reduce traffic in the OR, standardize skin prep and incision care orders and develop “lami checklist” for compliance auditing. .

Neurosurgeons were notified of intra-op non-compliance for follow-up.

Roll-out of checklist

Lami infection rates declined to <2% for two consecutive quarters. Peri-operative Services went live with a unified electronic charting system.

Checklist incorporated into electronic charting system.

Validated 100% compliance with key checklist elements. Infection rate <2%

for last 4 of 5 quarters. Wrap-up

of project; surveillance to

continue.

Timeline of Laminectomy SSI Improvement Project

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WHEW-dog tired?

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Questio

ns/

Discussi

on

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