SURGICAL SITE INFECTION SURVEILLANCE Training for data management, quality assurance and reporting

SURGICAL SITE INFECTION SURVEILLANCE

Training for data management, quality assurance and

reporting

Scottish Surveillance of HealthcareAssociated Infection Programme

Role of HPS

• To co-ordinate, facilitate and support the implementation of SSI surveillance

• To prepare Protocols• To prepare data collection tools• To support on-going data

management and ensure quality data

• To collate and report the national data set


Objectives:

• To describe and apply all data management points pertinent to the local and national management of data

• To apply quality assurance requirements to SSI surveillance data

• To develop reporting and mechanisms of feedback for surgical site infection data


Introduction to Surveillance

• Surveillance is the ongoing systematic Surveillance is the ongoing systematic collection, analysis, and interpretationcollection, analysis, and interpretation of health data essential to the planning, of health data essential to the planning, implementation, and evaluation of implementation, and evaluation of public health practice, closely integrated public health practice, closely integrated with the timely dissemination of these with the timely dissemination of these data to those who need to know. The data to those who need to know. The final link of the surveillance chain is the final link of the surveillance chain is the application application of these data to prevention of these data to prevention and control.and control.

(Centers for Disease Control and Prevention 1988)(Centers for Disease Control and Prevention 1988)

Objectives of surveillance

• Early warninginvestigation of problems and intervention to control

• Monitoring trends• Examining impact of interventions• To gain information on quality of

care• Targeting resources

Scottish SSI Surveillance Programme- The Surveillance Cycle

Data collection completed at site

Data collection completed at site

Data are sent to the local surveillance coordinator

Data are sent to the local surveillance coordinator

Data are quality checked and anonymised (Patient

identifying details removed)

Data are quality checked and anonymised (Patient

identifying details removed)

Data are sent to local nominated data transfer coordinator

(if required)

Data are sent to local nominated data transfer coordinator

(if required)

Forms sent to HPS by post or fax*

Forms sent to HPS by post or fax*

Data scanned at HPS and database with reporting facilities fedback to hospital

within 3 months

Data scanned at HPS and database with reporting facilities fedback to hospital

within 3 months

Electronic data transfer to HPS*

Electronic data transfer to HPS*

Collated for national reporting of

SSI surveillance

Collated for national reporting of

SSI surveillance

National ReportNational Report

Results fed back to

hospitals

Results fed back to

hospitals


Data Management


Aims of SSIS Programme

• Collect surveillance data on SSI’s to permit estimation of the magnitude of SSI risks in hospitalised patients

• Analyse and report SSI surveillance data and describe trends in infection rates

• Provide timely feedback of SSI rates to assist surgical units in minimising the occurrence of SSI’s


Data Management

What data?


Each Division should undertake surveillance on at least two of the following operation categories, hip arthroplasty & caesarean section must be undertaken if performed at site.Generic Cardiac Surgery, CABG, Abdominal

Hysterectomy, Caesarean Section, Major Vascular Surgery, Breast Surgery, Cranial Surgery.

Orthopaedic

Hip Replacement, Operations for Fractured Neck of Femur, Knee Replacement.

Data CollectionData Collection

Checking for Completeness and Accuracy

Checking for Completeness and Accuracy

Data InputData Input

‘Local’ Reporting‘Local’ Reporting

Quality Assurance Checking

Quality Assurance Checking

‘National’ Reporting‘National’ Reporting

Data Management Process

Alternative Data Management Scenarios

• ‘Local’ Data Management• Data Management at HPS• Data Transfer• The SSIS Database


Quality Assurance Workshop

• Collect completed forms• Check forms for completeness and

accuracy• Process the data into the database• Carry out QA Checking• Present your findings



Ensuring valid and reliable data through quality checks


AIM

• To promote valid and reliable data by performing thorough and appropriate quality checks


Objectives:

• To recognise the importance of appropriate data quality checks – both locally and nationally

• To understand how to perform quality checks on different aspects of data entry

• To be aware of the consequences of poor quality data


What would you look for in a quality product?

• A quality product is important to us all, SSI surveillance data is no different

• A lot of time and effort is put in by many people towards SSI surveillance data to ensure it is:– Valid– Reliable

• Everyone must have confidence in the data – that what is presented is a quality product !

Consequences of poor quality data

• Unreliable, invalid and subsequently inaccurate data

• Subjective outcome(s)• Waste of time !

Consequences of poor quality data

• Overestimated infection rates

• Underestimated infection rates

• Inappropriate change to evidence based practice

• No change to practice / infection rates !

Implications for Divisions

• Clinical Governance Agenda

• Quality Improvement Standards (CSBS)

• Performance Assessment Framework

• National Reporting

• Public Concern

The “5 Ws” for quality

• What – SSI surveillance data• Who – local and national teams• When – frequency of data

collection,collation and feedback• Where – local and national teams• Why – to ensure valid and

reliable data

Quality checks

• Manual/visual checks

• Automated Form Processing

• Standard queries within Microsoft Access database

Manual/visual quality checks• What• Who • When• Where • Why

• Data collection forms returned for collation to local co-ordinator– Forms visually checked for:

•Completeness•Accuracy

– Cleaning of data– Locating missing data

• Perform at least monthly, to avoid backlog

• Denominator checks also performed at this time, e.g. through theatre lists

• Essential to ensure data are accurate before sending to HPS and compiling reports for local feedback

Manual / visual quality checks

• Forms are received by SSHAIP team (HPS) from divisions (monthly)

• QA protocol is followed - forms are checked for:– Completeness – Accuracy

• Cleaning of data• Locating missing data

• What• Who • When• Where • Why

AFP quality checks

• Forms scanned (within the quarter)• ‘Validation rules’ (within Teleform)

– Locating missing data• Verification of fields prompted

– SSHAIP team verify queries• 1st 100 forms verified field by field

to be confident in level of accuracy• Thereafter, monthly 10% of forms

randomly checked field by field


Validation Rules

• Entries required• Date frames set, e.g.

age, date of admission, date of operation

• Time frames set, e.g. start time of operation, completion time of operation, date of confirmed SSI

MS Access Standard Query - Quality Checks• Standard queries written

include:– Lookup tables, e.g.

hospital codes, OPCS4 codes

– ‘Value’ checks, e.g. sex, category of procedure

– Date, time and value frames set, e.g. date of operation, BMI

– Accuracy checks, e.g. criteria for SSI and when SSI detected - against SSI present and date frames

• Queries run and verified (e.g.monthly) by SSHAIP team

• Anomalies checked, contact with local co-ordinator


Additional QA checks

• Annual case note review– 20 random case

notes reviewed against database

– SSHAIP team and local co-ordinators•Permission for

access– A report will be

fedback to all divisions

• Denominator checks– In addition to

division denominator checks the SSHAIP team will liaise with ISD to obtain denominators by hospital by procedure


Summary

• The importance of understanding:

– The processes for data entry

– The many data quality checks

– The responsibilities for quality checks, both locally and nationally

– The consequences of poor quality data

Data Reporting Workshop

• Workshops to:– Be familiar with reports that

can be obtained through MS Access database

– Consider use of these reports for the local feedback process

– Raise any issues with these reports

– Analyse reports to ensure they provide valid and reliable data

Reporting data

Reporting of data

Objectives:

• To develop an understanding of the local and national mechanisms of reporting SSI data

• To describe risk adjusted reporting

• To examine the different mechanisms which can be utilised for reporting data

Reporting ?

Requirements for successful surveillance

• Commitment of senior managers• Commitment of a

multidisciplinary staff• A suitable method for data

collection• A suitable method for reporting

HAI SSG Orthopaedic Subgroup J une 20022

HIS C

The “5 Ws” of data reporting

• What ?

• Who ?

• When ?

• Where ?

• Why ?

What ? – Feedback of data

• Graphs• Tables• Descriptive

statistics• Inferential

statistics

What ?Risk Index for SSI Surveillance

• SSI rates, by surgical procedure/category, which will be stratified by risk index.

• The NNIS risk index will be used for this. • This index scores each procedure according to

the presence or absence of three risk factors at the time of surgery and scores range from 0 (none of the factors present) to 3 (all of the factors present). The risk factors are:

– ASA score>=3– Wound classified as contaminated or

dirty– Duration of operation

NNIS Risk Index GraphPercentage of Operations & SSI rate by NNIS Score

45%41%

9%5%

50%

78%

100% 100%

0%5%

10%15%20%25%30%35%40%45%50%

0 1 2 3

NNIS Score

Perc

ent O

pera

tions

0%

20%

40%

60%

80%

100%

120%

SSI R

ate

(%)

% Operations

SSI Rate

EXIT

Who? – Presenting the data

• All stakeholders: All multidisciplinary involved in the surgical care pathway– Surgeons– Infection control

staff– Managers/

resources– HPS

When ? Where ?

• Regular feedback:– Active– Passive

• Denominator• At least quarterly

• Locally: by individual (anonymised)

• Nationally: HPS collate and present by Division

Why ?• Prevention (Haley et al)

– Engaged clinicians– Motivated Infection control staff– Intensive surveillance programme

• Hawthorne effect• Early identification of problem

trends/ outbreaks

• Resource allocation

Percentage of clean wounds infected per month

0

2

4

6

8

10

12

14

16

18

20

Nov

95

Dec

95

Jan

96

Feb

96

Mar

'96

Apr

'96

May

'96

Jun/

Jul '

96

Aug

'96

Sep

'96

Oct

'96

Nov

'96

Dec

'96

Jan

'97

Feb

'97

Mar

'97

Apr

'97

May

'97

June

'97

July

'97

Aug

'97

Sep

'97

Oct

'97

Nov

'97

Dec

'97

Jan

'98

Feb

'98

Mar

'98

Sep

'98

Oct

'98

Nov

'98

Month

% i

nfe

cte

d

Moving average based on last 6 months

Surgical Wound Infection Rate over by Audit Period

13.2%

11.1%

10.2%

7.8%

14.3%

8.3%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Baseline (Nov-Dec 95) After Feedback toSurgeons (Jan-May 96)

After Feedback to Wards(June-Dec 96)

Before Cessation ofSurveillance (Mar 98)

After Cessation (Sep 98) After FeedbackRecommenced (Oct-Nov

98)

% In

fect

ed

Surveillance Stopped

Scottish Centre for Infection and Environmental HealthA Division of the Common Services Agency

Source: Dr Ed Smyth

Wound surveillance nurse administrates the

project

Wound surveillance nurse administrates the

project

Wound surveillance nurse identifies patients from theatre lists

Wound surveillance nurse identifies patients from theatre lists

Demographic details…completed by wound

surveillance nurse on the ward pre-op

Demographic details…completed by wound

surveillance nurse on the ward pre-op

Patients with identified wound

problems are seen at wound surveillance clinics, or at home

by the wound surveillance nurse for wound review

Patients with identified wound

problems are seen at wound surveillance clinics, or at home

by the wound surveillance nurse for wound review

Patients are seen at wound surveillance clinics, or at

home by the wound surveillance nurse at day

30 post-op for wound review

Patients are seen at wound surveillance clinics, or at

home by the wound surveillance nurse at day

30 post-op for wound review

Operative details…completed by

wound surveillance nurse on the ward

post op

Operative details…completed by

wound surveillance nurse on the ward

post op

Patients have a 24 hour answer

service telephone number to call with wound problems. Primary care staff

also liaise with wound surveillance

nurse

Patients have a 24 hour answer

service telephone number to call with wound problems. Primary care staff

also liaise with wound surveillance

nurse

Daily visits to all surgical

wards to carry out wound

checks

Daily visits to all surgical

wards to carry out wound

checks

Wounds are checked before discharge from

hospital

Wounds are checked before discharge from

hospital

Data are managed and collated by

the wound surveillance nurse

Data are managed and collated by

the wound surveillance nurse

Data are graphed and fed back to the

surgeons, nurses and infection control

team on a monthly basis

Data are graphed and fed back to the

surgeons, nurses and infection control

team on a monthly basis

Conclusion

• SSI rates are key quality indicators for surgery

• Data must be complete

• Data must be reliable and valid

• Data must be reported back to clinicians

• Data must be acted upon

Summary

• Overviewed data management issues pertinent to the local and national management of data

• Developed an understanding of the local and national quality assurance requirements

• Aware of the importance of reporting and mechanisms of feedback of surgical site infection data

www.hps.scot.nhs.uk

SURGICAL SITE INFECTION SURVEILLANCE Training for data management, quality assurance and reporting

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