BEST PRACTICES FOR SURGICAL SITE INFECTION (SSI) Janet Sullivan RN, BSN, CIC November 20, 2013

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1 BEST PRACTICES FOR SURGICAL SITE INFECTION (SSI) Janet Sullivan RN, BSN, CIC November 20, 2013

2 LEARNING OBJECTIVES 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

3 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 3

4 IS YOUR FACILITY PARTICIPATING IN NHSN S PATIENT SAFETY, PROCEDURE-ASSOCIATED MODULE: SURGICAL SITE SURVEILLANCE? 4

Learning Objectives 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

5 Learning Objectives 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 5

6 Surgical Site Infection- Financial Cost 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 6

7 Surgical Site Infection-Human Cost 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 Tanner J, et al. Patients experience of surgical site infection. Journal of Infection Prevention. July 2012;13(4 7

ASC SSI reporting 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

8 ASC SSI reporting 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 8

9 ASC SSI reporting 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 9

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11 Learning Objectives 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 11

12 Step One: SSI surveillance 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 12

13 Examples 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 13

14 B. How do I know which category the procedure falls into? Go to: Scroll down to ICD-CM Procedure Code Mapping to NHSN Operative Procedure 14

15 NHSN 2014 changes 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

16 B. How do I know how long to follow the procedure for development of SSI? Go to: Scroll down to Protocols: SSI event 16

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18 Denominator list 18

19 Knowledge check Columbia River ASC has chosen to monitor knee arthroscopy chondroplasty (ICD 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

20 Step Two: SSI surveillance Decide on a surveillance method that will be used to capture potential SSIs S ur D vef ei in In ll iti tr ao ns d c& u e Pr ct Mot io et o n hc ol ds ol o g y Surgeons: Self report, mailed/faxed form Patients: Phone calls or mail survey Micro data: Wound cultures Pharmacy: Antibiotics prescribed Coding data: Office visit 20

21 Step two: Methods to identify potential SSIs TABLE 9. Summary Method of Literature Review Potential of Surgical Advantages Site Infection Potential Surveillance Disadvantages Practices Routine wound Conducted examination Non-Acute by High Care sensitivity Settings* and specificity Labor intensive, prospective only trained professional Outpatient chart review by trained professionals Surgeon Reporting Self Initiated Mail Survey High sensitivity and specificity Labor intensive High specificity, resource efficient Poor sensitivity Acceptable specificity, relatively Suboptimal sensitivity resource efficient Patient reporting Mail Survey Relatively resource efficient Unreliable sensitivity and specificity Telephone Survey Good public relations Labor intensive, unreliable sensitivity and specificity Microbiological data Claims data algorithm incorporating discharge diagnosis codes, procedure codes, pharmacological Rx date* Clinic notes text searching ** Relatively resource efficient, may flag potential SSIs Electronically available, increased sensitivity and positive predictive value Unreliable sensitivity and specificity. 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 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 Key References/Notes: Manian FA. Surveillance of in alternative settings: Exploring the current options. Am J Infect Control 1997;25: factors, attrition bias (f/u response *Yokoe DS, et al. Enhanced identification of postoperative infections among inpatients. Emerging Infectious Diseases 2004;10: not representative of the original 21

22 Sample: Surgeon Surveillance Form 22

23 SSI Learning Objectives 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 23

24 Surgical Site Infection (SSI) 24

25 Surgical Site Infection (SSI) 25

26 Surgical Site Infection (SSI) 26

27 Surgical Site Infection (SSI) 27

28 Which of these is/are considered primary closure? A Answer: A & B. Per NHSN if any part of the wound is approximated, it is conside primary closure B 28

29 Surgical Site Infection (SSI) 29

30 Surgical Site Infection (SSI) 30

Surgical Site Infection (SSI) For a selected group of NHSN Group of NHSN operative procedures: up to 90 days post op, monitor for deep incisional or organ/space For any/all NHSN procedures: In

31 Surgical Site Infection (SSI) For a selected group of NHSN Group of NHSN operative procedures: up to 90 days post op, monitor for deep incisional or organ/space For any/all NHSN procedures: In the first 30 days post op, monitor for superficial, deep, o organ/space Surveillance period for Deep Incisional or Organ Space SSI /page3934.html 31

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33 Surgical Site Infection (SSI) 33

34 Surgical Site Infection (SSI) 34

35 Surgical Site Infection (SSI) 35

36 Knowledge check You are doing surveillance on breast expander exchange to Is 30 a silicone day or 90 implant. day surveillance performed on You find that this the procedure? ICD 9 code for this procedure is 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. No doesn t occur within 30 Does days this meet post op criterion for superficial incisional SSI? 36

37 Surgical Site Infection (SSI) 37

38 Surgical Site Infection (SSI) 38

39 Knowledge check You are doing surveillance on cervical laminectomy procedures with 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? 39

Surgical Site Infection (SSI) http://www.cdc.

40 Surgical Site Infection (SSI) 40

41 Surgical Site Infection (SSI) 41

42 Surgical Site Infection (SSI) 42

43 Knowledge check You are doing surveillance on shoulder arthroscopic repairs. (ICD 9 is OTH code) Is 30 day or 90 day surveillance performed on this 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 Yes organism synovial fluid revealed isolated a WBC from count aseptically of obtained 15,000 with neutrophil at culture 77%, very of fluid low glucose and high protein level. Surgeon diagnosis patient with a surgical site infection. Does this meet criteria for superficial incisional Yes meets SSI? criteria b. of organ/space and of JNT criteria Does this meet criteria for Organ/Space infection? Which one would you report it as? Organ Space-JNT Always report the deepest level 43

44 Same patient-little different info Mrs. Post underwent this procedure on September 24 th 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 23 rd. 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 Does exam this of meet that revealed criteria for a WBC count of 15,000 with neutrophil Organ/Space at 77%, infection? very low glucose and high protein level Yes-meets c. of Organ/Space Meets #2 and # 3c of JNT 44

45 SSI scenario Mr. Rottman underwent a laparoscopic left inguinal hernia with mesh via total extraperitoneal (TEP) approach on October 28 th. The ICD-9 code was HER code. He returned to the surgeon s office on November 30 th 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 Does diagnosed this meet criteria patient for with superficial surgical site SSI? infection. 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 in a. purulent drainage from the deep incision (DIP) 45

46 SSI scenario 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 FX code. She returned to the surgeon s office on October 15 th with increasing redness, pain, heat and scant serosanguineous drainage at her surgical incision. No cultures are done. The surgeon diagnosis the patient Does this meet criteria for No SSI? with cellulitis and prescribes Keflex for two weeks. The patient returns to the office in two days (Oct 17 th ) 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 Does documents this meet poor criteria wound No healing. He changes her antibiotic for SSI? therapy to Bactrim. The patient returns in three weeks later (Nov 17 th ) with fever C 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 Which category? Deep incisional for SSI? primary (DIP) 46

47 SSI Numerator Collection Forms 47

48 SSI Collection Form Alternative (if not reporting in NHSN) 48

49 SSI Learning Objectives 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 49

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

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52 Display of SSI organisms 52

53 1.2 Timeline of Events: Craniotomy Surgical Site Infection Reduction Timeline of Project Laminectomy SSI Improvement Project ASC IP notified of an increase in laminectomy infections. Neurosurgeons were notified of intra-op noncompliance for follow-up 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%. Lami infection rates declined to <2% for two consecutive quarters. Peri-operative Services went live with a unified electronic charting system Periop: promote pre-op showers, am pre-op CHG cloth wipe, eliminate multiuse patient items, reduce traffic in the OR, standardize skin prep and incision care orders and develop lami checklist for compliance auditing.. Roll-out of checklist 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.

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55 WHEW-dog tired? Questio ns/ Discussi on 55

56 Participation Code The 5 digit confirmation code for this webinar is: You will be asked to enter this in the evaluation

SURGICAL SITE INFECTIONS: SURVEILLANCE & PREVENTION

SURGICAL SITE INFECTIONS: SURVEILLANCE & PREVENTION Facts There were an estimated 157,500 surgical site infections associated with inpatient surgeries in 2011. SSIs were the most common healthcare-associated