Where we started and where we’re going…

Anjum Khan MBBS MSc CICInfection Control Professional

Department of Risk Management and Quality Improvement

Infection Prevention & Control Service

Surgical Site Infection (SSI)Surgical Site Infection (SSI)Surveillance UpdateSurveillance Update

(with special reference to Colorectal Surgeries)(with special reference to Colorectal Surgeries)

OutlineIntroduction

Our SSI Surveillance Framework

NNIS/NHSN definitions and Risk Stratification Methods

Data on Process Indicators

Challenges

IntroductionSurgical Site Infections (SSI) are the second most common type of adverse event in hospitalized patients

SSI increase mortality, readmission rate, length of stay and cost of care

SSIs are preventable

Surveillance first step towards any prevention strategy

Objectives of SSI SurveillanceTo measure baseline rates and performances

To monitor process indicators as the appropriateness of antimicrobial prophylaxis ordered and given to the patient

Systematic reporting and regular feedback to all stakeholders such as individual Surgeons, Medical and Program Directors and the Chief of Surgery to engage their attention for Patient Safety and Continuous Quality Improvement (CQI) programmes

To drive the conduct of interventions that reduce the surgical site infection rates and morbidity and mortality associated with it

Accreditation Requirement

Surveillance ByInfection Control Professional

Department of Risk ManagementSSI Surveillance Framework

MDT RoundsM &M Rounds

ER Admission list

Review ofMicrobiology culture

reports

Post Discharge SSI Form Surgeon Self Reporting

Denominator data- OR data base

Review by IC service

Report to Division Head, Program DirectorPeri operative Directors

Surgeon in Chief & individual surgeons

Service reportsICC, SMC, MAC

Board-Balanced Score Card

Recommendations for altering

any processes

ASS

ESS

ME

NT

AN

AL

YSI

SA

CT

ION

Calculation of crude and Risk Stratified rates

Surveillance ByInfection Control Professional

Department of Risk ManagementSSI Surveillance Framework

MDT RoundsM &M Rounds

ER Admission list

Review ofMicrobiology culture

reports

Post Discharge SSI Form Surgeon Self Reporting

Denominator data- OR data base

Review by IC service

Report to Division Head, Program DirectorPeri operative Directors

Surgeon in Chief & individual surgeons

Service reportsICC, SMC, MAC

Board-Balanced Score Card

Recommendations for altering

any processes

ASS

ESS

ME

NT

AN

AL

YSI

SA

CT

ION

Calculation of crude and Risk Stratified rates

SSI Surveillance for Selected Procedures

Cardiovascular (1998/1999)Ophthalmology (2001)Neurosurgery (Jan- 2006)General surgery (March- 2006)Obstetrics (June- 2006)Orthopedics (Jan- 2005)Vascular (TBD, initiated the discussions)

Selected Procedures in General Surgery

Colorectal Surgeries – March 2006

Quality/Outcome Indicators-Rate of SSI among wound class I and II

Process Indicators-% of surgical patients receiving appropriate abx within 1 hour of cut time- % of surgical patients with normothermia

in PACU (36-380C)

SSI Surveillance MethodsInpatient SSI Surveillance

MDT RoundsM&M RoundsMicrobiology ReportsDaily Admission list

Post Discharge SSI SurveillancePost discharge Surveillance form

SSI Risk StratificationPredictors of SSI Risk

Host susceptibility-ASA score

Degree of microbial contamination of surgical site

Duration of operation

SSI Risk Stratification-cont’dNNIS Risk Index

ASA > 2 =1

Contaminated or dirty/infected wounds=1

Length of operation >T hours (T=75%ile)=1

NNIS Risk Index can range from 0-3

SSI Risk Stratification- cont’d

Laparoscopic Procedures

1 is subtracted from the calculated NNIS Risk Index e.g. when 2 risk factors are present and the procedure is done laparoscopically the new modified risk index category is 1 (i.e., 2-1=1)

When no risk factors are present and the procedure is performed with a laparoscope the risk category is 0-1=-1. “ -1=M ”

SSI can be classified as: (CDC)

1. Superficial incisional-skin and subcutaneous tissue involvement

2. Deep incisional-Muscle and fascial layer

3 Organ/Space – Organs/structures beneath the area of incision

58%

7.2%

34.5%

Calculating SSI RatesNumerator Definition

Number of clean surgery patients (wound class I & II) having a post operative wound infection

Denominator DefinitionNumber of clean surgery patients (wound class I & II)

Exclusion CriteriaPatients < 18 years of ageSurgeries classified as wound class III & IV

SSI Rate = Numerator x 100Denominator

Percent of Surgical Patients w ith Antibiotic Administration Within 60 minutes Prior to Surgical Incision for Colon Surgery

020406080

100120

Apr-06 M ay-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 M ar-07 Apr-07 M ay-07 Jun-07

Months

Perc

enat

ge

Series1 55.00 69.57 42.86 72.73 55.56 88.24 80.00 100.00 100.00 71.43 92.86 92.31 92.31 94.12 86.67

Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07

Percentage of Colorectal Surgery Patients with Antibiotic Administration

Within 60 minutes Prior to Surgical Incision

SHN Target=95%

Percent Colon Surgery Patients with Normothermia in PACU

0

20

40

60

80

100

Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07

Months

Perc

enta

ge

Series1 15.00 56.52 47.62 18.18 44.44 47.06 60.00 50.00 25.00 78.57 50.00 23.08 30.77 35.29 46.67

Apr-06 May- Jun-06 Jul-06 Aug- Sep- Oct- Nov- Dec- Jan-07 Feb- Mar- Apr-07 May- Jun-07

Percentage of Colorectal Surgery Patients with Normothermia in PACU (36-38)

THE LANCET Vol 358: Sept 15, 2001THE NEW ENGLAND JOURNAL OF MEDICINE Vol 334, No 19, 1996

SHN Target=95%

Percentage Return Rateof Post Discharge Surveillance Forms

0

10

20

30

40

50

60

Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07

Months

Perc

enta

ge

27.27 11.11 52.94 20.00 27.78 33.33 21.43 25.00 31.25 7.69 17.65 26.67 6.67 11.76

Jul-06 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul-07 Aug-

53% Returns from our own Surgeons19% of returned forms reported an infection

Between 12% and 84% of SSI are detected after patients are discharged from the hospitalInfection Control and hospital Epidemiology Apr 1999; 20,4250-269

ChallengesWound ClassificationAssign the surgical wound classification upon completion of an operation. A surgical team member should make the assignment. CDC Recommendation Category II

Manual Data Abstraction

Return Rate of Post Discharge SSI forms When post discharge surveillance is performed for detecting SSI following certain

operations, use a method that accomodates available resources and data needsCDC Recommendation Category II

Challenges-cont’dBreakdowns in delivery of Post Discharge Surveillance Form

Placement in the chartCorrect placement in the chartDelivery and proper instructions by RNPatient bringing the form to Surgeon/GPSurgeon/GP sending the form back to us

– Don’t seem to have any control over last 2 factors

Preventing Surgical Site InfectionFour Components of Care

Appropriate Hair Removal

Appropriate Use of Prophylactic antibiotics

Maintenance of Post Operative Glucose Control

Peri Operative Normothermia (Colorectal Surgeries)

PLAN

DO

STUDY

ACT

Questions ?