Categorizing Wound Infections: A Comparison between ACS-NSQIP and an Institutional Surgical Secondary Events Database

Transcription

1 : A Comparison between ACS-NSQIP and an Institutional Surgical Secondary Events Database Luke V. Selby MD, Daniel D. Sjoberg MS, Danielle Cassella MA, Mindy Sovel MPH MS, David R. Jones MD, Vivian E. Strong MD www. MSKCC.org/sse

2 Disclosures Nothing to Disclose

3 Background Surgical Site Infections (SSIs) account for between 20 30% of all healthcare-associated infections (HAIs) and can cost between $20,000 - $27,000 per infection Reducing HAIs is a priority goal for the Department of Health and Human Services Memorial Sloan Kettering Cancer Center uses two primary systems to track SSIs department wide NSQIP Surgical Secondary Events (SSE) Database Both known to identify greater than 90% of post-operative adverse events, but have never been directly compared. Also track SSIs for all colectomies, abdominal hysterectomies, and hip replacements (NYS mandate)

4 MSKCC Surgical Secondary Events Database Developed in 2001 as a modification of the Clavien Dindo classification Department wide, prospective, severity graded database tracking 30-day post-operative secondary events 14 categories with over 220 defined and graded complications Audited in 2009 Correctly classified 91% of all patients Audit results presented at 2013 NSQIP conference Aim Validate SSE database recording to ACS-NSQIP s nationally validated methods and definitions Different methods Different timelines Different definitions

5 Surgical Secondary Events Classification Grade Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Surgical Secondary Event Requiring or Resulting in: Bedside Care or Oral Medications Intervenous Medications, Transfusion Radiologic, Endoscopic, or Operative intervention required Chronic Disability or Organ Resection Death Minor Major Body Systems Cardiovascular System Endocrine System Gastrointestinal System General Genitourinary System Head and Neck Hematologic or Vascular System Infection Metabolic Musculoskeletal System Nervous System Pain Pulmonary System Wound or Skin

6 Methods Direct comparison of NSQIP and SSE database for 2011 and 2012 NSQIP panel 5,028 patients While blinded to NSQIP results, entries in the SSE database were categorized as possibly representing an incisional infection (superficial or deep incisional infection) or an organ space infection. Discordant charts were reviewed by hand (while blinded to NSQIP or SSE results) and categorized according to both NSQIP scoring (SSI, DSI, OSI, or None) and SSE scoring (Name & Grade of Event)

7 Incisional Infection Definitions MSKCC Wound Infection CDC guidelines for diagnosis of wound infection or requiring therapy Cellulitis Erythema surrounding wound without associated pus, with or without fever and requiring therapy Wound Breakdown Wound separation, breakdown or epidermolysisrequiring significant local wound care FascialDehiscence or Evisceration Fascialbreakdown with evidence of serous peritoneal fluid or disruption of flap closure NSQIP Superficial Skin Infection Purulent drainage; or positive culture; or opened with either pain/tenderness, swelling, erythema and warmth (unless culture negative) Deep Skin Infection Purulent drainage not from the organ/space component; or a deep incision that spontaneously dehisces or is opened with fever or localized pain / tenderness (unless culture negative); abscess or infection found on direct exam, reoperation, histology, or imaging

8 Organ Space Infection Definition MSKCC Intra-Abdominal Abscess Clinical or radiologic diagnosis of intra-abdominal abscess or peritonitis Anastomotic Leak (Biliary, Intestinal, Esophageal, Pancreatic, or Rectal) Anastomotic Leak Non-infected Intra-abdominal / Intra-thoracic fluid collection Postoperative fluid collection negative for microorganisms, amylase and bilirubin Fistula (Biliary, Intestinal, Esophageal, Pancreatic, or Urinary) Clinical S/S of fistula with drainage >50ml/day after POD #5 NSQIP Organ Space Infection Purulent drainage from a drain (not placed during operative procedure); positive culture from an aseptically placed drain; abscess or infection found on direct exam, reoperation, histology, or imaging

9 Surgical Site Infection Rates Surgical Site Infection NSQIP SSE Agreement 4% 7% 95% kappa = 0.48, p < Incisional Infection 3% 4% 96% kappa = 0.36, p < Organ Space Infection 2% 3% 98% kappa = 0.55, p <

10 SSE Database Discordance Infection Level SSE NSQIP Incisional 205 NSQIP Identified: 65 (31%) NSQIP Not Identified: 140 (69%) Criteria: 21 (15%) No Criteria: 119 (85%) Organ Space 141 NSQIP Identified: 62 (44%) NSQIP Not Identified: 79 (56%) Criteria: 14 (18%) No Criteria: 65 (82%)

11 Blinded Review Results SSE Over-Identification Due to event not meeting NSQIP definition ISI: Incision (no heat / pain) opened at bedside without drainage or culture negative OSI: Non-purulent, culture-negative, drainage from post-operative fluid collection SSE Misses Majority (60%, 25 / 42) of non-documented events occurred after initial hospitalization Majority (79%, 33 / 42) of non-documented events were incisional infections Majority (67%, 24 / 42) of non-documented events were Minor (Grades 1 & 2)

12 Conclusion MSKCC SSE and NSQIP show significant agreement in rates of categorized wound infection MSKCC SSE can be used as a real-time surrogate of wound infection rates while awaiting validated and risk-adjusted NSQIP results Accurately captures post-operative events on 100% of patients in real time Severity based scoring of post-operative events Data collection by clinicians can be used prior to full SCR review