SURGICAL SITE INFECTIONS: SURVEILLANCE & PREVENTION

Transcription

1 SURGICAL SITE INFECTIONS: SURVEILLANCE & PREVENTION

2 Disclosures: I have No conflicts of interest No commercial support No specific product will be endorsed during this presentation

3 Facts There were an estimated 157,500 surgical site infections associated with inpatient surgeries in SSIs were the most common healthcare-associated infection, accounting for 31% of all HAIs among hospitalized patients. SSIs account for $3.2 billion in attributable cost per year in acute care hospitals. SSIs are associated with a 3% mortality rate, estimated 8,205 deaths annually. 11% of all deaths in ICUs are associated with SSI. 75% of SSI-associated deaths are directly attributable to the SSI.

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6 NHSN Operative Procedure Occurs on Inpatient or Outpatient Included in procedure list: Takes place in an operating room Meets AIA criteria OR, C-Section room, Interventional radiology room, cardiac cath lab takes place during an operation (defined as a single trip to the OR) where at least one incision is made through the skin or mucous membranes (includes laparoscopic approach), or reoperation via an incision that was left open during a prior operative procedure Incisional closure method is NOT part of definition

7 NHSN Inpatient Operative Procedure NHSN Inpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and the date of discharge are different calendar days.

8 NHSN Outpatient Operative Procedure NHSN Outpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and date of discharge are the same calendar day.

9 How do I find out if a procedure falls under one of the NHSN operative categories? You can look for the ICD-10-CM here. Document found under Supporting Materials section of SSI Protocol

10 Primary Closure Primary Closure = closure of the skin level during the original surgery, regardless of the presence of wires, wicks, drains, or other devices or objects extruding through the incision, includes surgeries where the skin is closed by some means. Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery. NOTE: If a procedure has multiple incision/laparoscopic trocar sites and any of the incisions are closed primarily, then the procedure is entered as having been closed primarily. This change removed the phrase all tissue levels from the definition. This definition will be easier to apply and is closer to definitions used by other surgical professional groups.

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12 Non- Primary Closure Skin level is left completely open during the original surgery Deep tissue layers may be closed by some means (with the skin level left open), or the deep and superficial layers may both be left completely open. Wounds with non-primary closure may or may not be described as "packed with gauze or other material, and may or may not be covered with plastic, wound vacs, or other synthetic devices or materials. For example: a laparotomy in which the incision was closed to the level of the deep tissue layers, sometimes called fascial layers or deep fascia, but the skin level was left open. For example: an open abdomen case in which the abdomen is left completely open after the surgery.

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14 ase 1 A patient is admitted with a ruptured diverticulum nd a COLO procedure is performed in the inpatient R. Case is entered as a wound class 3 Specimen is obtained in the OR which later returns ) for E. coli Surgeon staples closed the skin at 4 locations with acking placed between the staples.

15 s this procedure primarily losed for 2016?. Yes. No

16 s this procedure primarily losed for 2016?. Yes. No

17 ase 1 -Rationale The skin is closed at some points along the skin cision. hus, if any portion of the incision is closed at the kin level, by any manner, a designation of primary losure should be assigned to the surgery.

18 f you are following COLO in your onthly reporting plan should his case be entered into your enominator data? 1.Yes 2.No

19 f you are following COLO in your onthly reporting plan should his case be entered into your enominator data? 1.Yes 2.No

20 Surveillance Surveillance of SSIs with feedback of appropriate data to surgeons has been shown to be an important component of strategies to reduce SSI risk. A successful surveillance program includes the use of epidemiologically sound infection definitions and effective surveillance methods, * stratification of SSI rates according to risk factors associated with SSI development, and * data feedback. Recommendations are outlined in the CDC s Guideline for Prevention of Surgical Site Infection, A new HICPAC guidelines for prevention of SSIs is scheduled for publication soon

21 CDC Definitions NHSN manual from Jan urrent.pdf Read the fine print 3 Types Superficial Incisional SSI Deep Incisional SSI Organ/ Organ Space

22 Sources of Data for Finding SSI Microbiology reports Infection control rounds on nursing units Pharmacy reports for antimicrobial use Operating room report of surgeries Use post-discharge surveillance methods for SSI Electronic Surveillance Programs ER Diagnosis List Case Managers IPs in your community!

23 Important Information! Please note that key terms that have been defined in other NHSN trainings (e.g. CLABSI, CAUTI) including Infection Window Period, Present on Admission (POA), Healthcareassociated Infection (HAI), and Repeat Infection Timeframe (RIT) DO NOT apply to SSI!

24 Date of Event Date of event (DOE): For an SSI the date of event is the date when the first element used to meet the SSI infection criterion occurs for the first time during the surveillance period.

25 DOE for SSIs that progress to a deeper level during surveillance period SSIs are always reported at the deepest level that they occur within the surveillance period. If during the surveillance period a patient s initial SSI meets criteria for a deeper level, then the date of event should be the date for the deepest level.

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27 Example For example: Day 1 COLO procedure Day 6 DOE for meeting a superficial incisional SSI Day 25 DOE for the meeting an organ space IAB SSI Only report one SSI with the DOE for the organ space IAB.

28 Pathogen Assignment The Pathogen Assignment Guidance found in Chapter 2 Identifying HAIs is based on Repeat Infection Timeframes (RIT) which is not used with SSIs SSI are procedure based and have long surveillance periods (30 to 90 days) SSIs can progress to a deeper level during a surveillance period and a new pathogen can be found. Pathogen Assignment for SSI has not changed.

29 Diabetes NHSN has added another option for users to answer the question of diabetes on the denominator for procedure form. NHSN users can chose to use, assignment of the discharge ICD-10-CM codes in the E10.10 to E13.9 range to answer YES to this diabetes field question. Definition includes those with diagnosis of diabetes requiring management with insulin or a non-insulin anti-diabetic agent. Definition excludes people who receive insulin for perioperative glucose control but have no diagnosis of diabetes.

30 BSI Secondary to an SSI Secondary BSI Attribution Period: The secondary BSI attribution period for SSI is a 17-day period that includes the date of SSI event, 3 days prior and 13 days after. For other HAIs the Secondary BSI attribution period is determined by using the Infection Window Period and the Repeat Infection Timeframe. These two definitions do not apply to SSI.

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32 Any blood culture that occurs during the SSI Secondary BSI attribution period will be assessed using Appendix 1 in the BSI protocol to determine if the blood meets Secondary BSI criteria. If a (+) blood culture occurs after the SSI secondary BSI attribution period it should be fully evaluated to see if at that time it is meeting criteria to be secondary to an ongoing SSI.

33 PATOS- Infection present at time of surgery nfection present at time of surgery (PATOS) denotes there is vidence of an infection present at the time of the start of or during he index surgical procedure (in other words, it is present preperatively). his field is a required field and it is found on the SSI event form not n the denominator for procedure form. ATOS does not apply if there is a period of wellness between the ime of a pre-operative condition and the surgery. he evidence of infection must be noted/documented reoperatively or found intra-operatively in a pre-operative or intraperative note.

34 Only select PATOS = YES if it applies to the depth of SSI that is being attributed to the procedure (e.g., if a patient had evidence of an intra-abdominal infection at the time of surgery and then later returns with an organ space SSI the PATOS field would be selected as a YES. If the patient returned with a superficial or deep incisional SSI the PATOS field would be selected as a NO).

35 The patient does not have to meet the NHSN definition of an SSI at the time of the primary procedure but there must be notation that there is evidence of infection or abscess present at the time of surgery.

36 NSHN is going to rebaseline all HAIs based on 2015 data. The 2015 data reported to NHSN will provide the baseline for calculating the Standardized Infection Ratio (SIR) for 2016 and subsequent years. SIRs calculated for the 2015 data will use the current baselines. SSIs reported with PATOS = YES will be excluded from the SSI SIR beginning with 2016 data and the new baseline. These excluded SSIs will be analyzed separately.

37 ase 2 Patient was admitted with an acute abdomen, to OR for XLAP with findings of an abscess due to ruptured appendix and an APPY is performed. Patient returns 2 weeks later and meets criteria for an organ space IAB SSI.

38 Does this patient meet the criteria for PATOS? 1. PATOS= NO 2. PATOS= YES

39 Does this patient meet the criteria for PATOS? 1. PATOS= NO 2. PATOS= YES

40 Since this SSI is related to an infection that was PATOS it does not have to be reported to NHSN. 1. True 2. False

41 Since this SSI is related to an infection that was PATOS it does not have to be reported to NHSN. 1. True 2. False

42 ase 2 -Rationale The PATOS field would be selected as YES since there was evidence of infection at the time of surgery and the subsequent SSI developed at the same level. Infections that meet SSI criteria and have the PATOS field as a YES are reported to NHSN.

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45 ICD-10-CM

46 ICD-10-CM ICD-10-CM

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52 Case 3: A patient had bilateral knee prostheses (KPRO) implanted during a single trip to the OR. Left KPRO PST at 8:30 am there was no note of a finish time for this knee Right KPRO PF time was at 11:30 am

53 Which Statement is correct? 1. One KPRO procedure should be reported with a combined duration of 3 hrs 0 min 2. Two Separate KPRO procedures should be reported, each with a duration of 1 hr 30 min 3. Two separate KPRO should be entered, each with a duration of 3 hrs 0 min

54 Which Statement is correct? 1. One KPRO procedure should be reported with a combined duration of 3 hrs 0 min 2. Two Separate KPRO procedures should be reported, each with a duration of 1 hr 30 min 3. Two separate KPRO should be entered, each with a duration of 3 hrs 0 min

55 Same NHSN operative procedure via separate incisions: For operative procedures performed via separate incisions during same trip to operating room (i.e., AMP, BRST, CEA, FUSN, FX, HER, HPRO, KPRO, LAM, NEPH, OVRY, PVBY, REFUSN), separate Denominator Procedure forms are completed. To document the duration of the procedures, indicate the procedure/surgery start time to procedure/surgery finish time for each procedure separately or, alternatively, take the total time for the procedures and split it evenly between procedures. SSI Chapter : Denominator Data Reporting Instructions

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57 Procedures that can never be coded as clean wound class he procedures that can never be entered as clean are: PPY, BILI, CHOL, COLO, REC, SB and VHYS. In the pplication, clean is not on the drop down menu. CSEC, HYST, or OVRY can be a clean wound class based n the particular events and findings of an individual case. ound class should be set by someone who is part of the urgical team based on the findings of each pecific case.

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69 Reporting Instruction : Labor Length of time from beginning of active labor as an inpatient to delivery of the infant, expressed in hours No labor, hours = 0 Check for documentation in the chart May be defined by your hospital s policies and procedures but should reflect the onset of regular contractions or induction that leads to delivery during this admission

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72 HPRO and KPRO Revisions If performed, evaluate whether any diagnoses indicating possible infection (acquired absence of hip joint, with or without the presence of an antibiotic-impregnated spacer or acquired absence of knee joint, with or without the presence of an antibiotic impregnated spacer) or any procedures such as insertion or replacement of cement spacer or removal of cement spacer were coded in the 90 days prior to and including the index HPRO or KPRO revision. This field will only open on the application if the case has been entered as a HPRO or KPRO revision.

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74 CDC Definitions Superficial (Primary or Secondary) Infection occurs within 30 days after NHSN operative procedure And Infection involves only skin or subcutaneous tissue of the incision And patient has at least one of the following: Purulent drainage from superficial incision Organisms identified from aseptically obtained specimen from superficial incision or subcutaneous tissue by a culture or non-cultured based microbiologic testing method (not Active Surveillance Culture/Testing) Superficial incision that is deliberately opened by a surgeon, attending physician or other designee and culture or nonculture based testing is not performed AND Patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; erythema; or heat. A culture or non-culture based test that has a negative finding does not meet this criterion. Diagnosis of a superficial incisional SSI by the surgeon or attending physician or other designee

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76 Reporting Instructions Multiple tissue levels are involved in the infection: The type of SSI (superficial incisional, deep incisional, or organ/space) reported should reflect the deepest tissue layer involved in the infection during the surveillance period.

77 Superficial Incisional SSI Reporting Diagnosis/treatment of cellulitis (redness/warmth/swelling), by itself, does not meet criterion d for superficial incisional SSI. An incision that is draining or culture (+) is not considered a cellulitis. A stitch abscess alone (minimal inflammation and discharge confined to the points of suture penetration) is not considered an SSI. A localized stab wound or pin site infection. While it would be considered either a skin (SKIN) or soft tissue (ST) infection, depending on its depth, it is not reportable under this module. Note: a laparoscopic trocar site for an NHSN operative procedure is not considered a stab wound.

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81 ase 4: 2/18: 45-year-old male admitted and had a laparoscopic left hemicolectomy (COLO).There was no evidence of infection noted at the time of surgery. Three trocar sites were closed and the fourth was left open and used for placement of a JP drain. 2/24: Purulent drainage noted at one of the trocar sites. Culture obtained and was (+) for Enterobacterspp. and E. coli; patient started on antibiotics.

82 Is this procedure primarily closed for 2016? 1. Yes 2. No

83 Is this procedure primarily closed for 2016? 1. Yes 2. No

84 Rationale Surgeon is using the existing trocar site to place the JP drain rather than creating another stab wound for the same purpose. If there are multiple incisions, if one of them is primarily closed it is considered a primarily closed procedure.

85 What should be reported to NHSN? 1. Nothing, the surgeon did not open the wound, so the criteria are not met 2. Nothing. It is an SSI, but not an HAI. 3. SSI-SIP 4. SSI-DIP

86 What should be reported to NHSN? 1. Nothing, the surgeon did not open the wound, so the criteria are not met 2. Nothing. It is an SSI, but not an HAI. 3. SSI-SIP 4. SSI-DIP

87 Rationale erficial Incisional SSI nfection occurs within 30 days after any NHSN operative procedure (where day 1 = he procedure date) AND nvolves only skin and subcutaneous tissue of the incision AND atient has at least one of the following: a. purulent drainage from the superficial incision. b. organisms isolated from an aseptically-obtained culture from the superficial incision or subcutaneous tissue by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture Testing (ASC/AST).. c. superficial incision that is deliberately opened by a surgeon, attending physician** or other designee and is culture positive or not cultured AND atient has at least one of the following signs or symptoms: pain or tenderness; ocalized swelling; erythema; or heat. A culture or non-culture based test that has a egative finding does not meet this criterion.. diagnosis of a superficial incisional SSI by the surgeon or attending physician** r other designee.

88 The PATOS field should be selected as: 1. PATOS=NO 2. PATOS=YES

89 The PATOS field should be selected as: 1. PATOS=NO 2. PATOS=YES

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91 Deep Incisional SSI An Infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according to the procedure list AND Involves deep soft tissues of the incision (e.g. fascial and muscle layers) AND

92 atient has at least one of the following:. Purulent drainage from the deep incision.. A deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician or other designee and organism is identified by a culture or non-culture based microbiologic testing method (not ASC/AST) or culture or non-culture based microbiologic testing method is not performed AND atient has at least one of the following signs r symptoms: fever (>38.0); localized pain or tenderness. culture negative finding does not meet this criterion.

93 c. an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam, or imaging test.

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95 se 5: 3/12 -Patient is admitted to the hospital for elective surgery and active MRSA screening test is positive. On the same day, patient undergoes total abdominal hysterectomy (HYST). No evidence of infection at the time of the surgery. 03/15 -Postoperative course is unremarkable; patient discharged. 3/18 -Patient is readmitted with complaints of acute incisional pain since day before. Surgeon opens the wound and notes that the fascia was not intact and sends a specimen from the deep wound. 3/20 Culture results are positive for MRSA. 3/25 Patient spikes temp and blood cultures obtained are (+) for MRSA

96 s this an SSI?. Yes, meets criteria. No, colonized with MRSA so this was POA

97 s this an SSI?. Yes, meets criteria. No, colonized with MRSA so this was POA

98 hat infection should be reported?. SSI-SIP. SSI-SIS. SSI-DIP. SSI-DIS. SSI-IAB

99 hat infection should be reported?. SSI-SIP. SSI-SIS. SSI-DIP. SSI-DIS. SSI-IAB

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101 Does this patient have a secondary BSI attributable to the SSI? Yes No

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103 Organ/Space SSI Infection fection occurs within 30 or 90 days after the NHSN erative procedure (where day 1 =procedure date) cording to the procedure list AND fection involves any part of the body deeper than the scial/muscle layers, that is opened or manipulated during e operative procedure AND

104 tient has at least one of the following: Purulent drainage from a drain that is placed into the organ/space (e.g. closed suction drainage system, open drain, T-tube, CT Guided drainage). Organisms isolated from an aseptically-obtained fluid or tissue in the organ/space by a culture or non-culture based microbiologic testing method (not ASC/AST). An abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test AND Meets at least one criterion for a specific organ/space infection site listed. These criteria are in the Surveillance Definitions for Specific Types of Infections Chapter.

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109 Reporting Instruction ttributing SSI to an NHSN procedure when there is vidence of infection at the time of the primary surgery: OA definition does not apply to the SSI protocol. If there as evidence of infection at the time of the procedure and en later in the surveillance period the patient develops an fection that meets the NHSN SSI criteria, it is attributed to e procedure. A high level wound class is not an exclusion r a patient later meeting criteria for an SSI.

110 ase 6: On 2/1 -Patient presents to ED with acute abdomen and is admitted to the OR on the same day for colon resection (COLO). Peritoneal abscess noted at time of surgery. Abdominal abscesses drained and thorough abdominal washout, incision loosely closed with some packing between staples and a JP drain is placed in an adjacent stab wound. 2/4 -Patient discharged, wounds healing well. 2/8 -Patient presents to ED with fever, abdominal pain, and sent to CT for CT guided drainage of an abscess. This is reported as an SSI-IAB (meets IAB criterion b and 3a.) The PATOS field would be entered as a YES

111 If during the post-operative period the surgical site has an invasive manipulation/accession for diagnostic or therapeutic purposes (e.g., needle aspiration), and following this manipulation/accession an SSI develops, the infection is not attributed to the operation. This reporting instruction does NOT apply to closed manipulation (e.g., closed reduction of a dislocated hip after an orthopedic procedure). Invasive manipulation does not include wound packing, or changing of wound packing materials as part of postoperative care.

112 Reporting Instructions In Chapter 9, the Reporting Instructions in the SSI criteria table, the Numerator Data section and the Table of Instructions provide important guidance on the many nuances of how to report SSI details in a variety of situations. The examples shown in this presentation are only some of them. Please read and follow all of the instructions carefully

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114 se 7: 3/10 Patient admitted and underwent a hemicolectomy due to colon cancer. Wound class=clean contaminated. 3/14 Temp up to 38.7C, abdominal pain. US shows intraabdominal abscess 3/15 To OR for I&D of the abscess. Abscess specimen collected and grew E coli. 3/18 Discharged from hospital on oral antibiotics

115 Does this patient meet criteria for an organ space SSI? 1. Yes 2. No

116 Does this patient meet criteria for an organ space SSI? 1. Yes 2. No

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118 2 different criteria must be met for Organ/Space SSI SSI organ/space criteria AND Those of the specific site of the organ/space operated on.

119 hat site specific SSI does this atient have?. SSI-SIP. SSI-DIP. SSI-IAB. SSI-GIT

120 hat site specific SSI does this atient have?. SSI-SIP. SSI-DIP. SSI-IAB. SSI-GIT

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128 se 8: 22: Pt has an abdominal hysterectomy (HYST) 1: Pelvic Pain; Temp 38.4 C 2: MRI reveals an abscess/fluid collection in the ep pelvic tissue 3: Surgeon opened wound in the OR and drained rulent fluid; specimen to lab for culture; notes fected hematoma ; antibiotics begun; incision sed primarily 5: Culture positive for Pseudomonas aeruginosa

129 hat should be Reported?. SSI-IAB. SSI-OREP. SSI-EMET

130 hat should be Reported?. SSI-IAB. SSI-OREP. SSI-EMET

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133 Questions?