Surgical Site Infection (SSI) Surveillance Update (with special reference to Colorectal Surgeries) Where we started and where we re going Anjum Khan MBBS MSc CIC Infection Control Professional Department of Risk Management and Quality Improvement Infection Prevention & Control Service
Outline Introduction Our SSI Surveillance Framework NNIS/NHSN definitions and Risk Stratification Methods Data on Process Indicators Challenges
Introduction Surgical 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 Surveillance To 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
Department of Risk Management SSI Surveillance Framework ASSESSMENT MDT Rounds M &M Rounds ER Admission list Surveillance By Infection Control Professional Review of Microbiology culture reports Post Discharge SSI Form Surgeon Self Reporting Denominator data - OR data base ANALYSIS Calculation of crude and Risk Stratified rates Review by IC service Report to Division Head, Program Director Peri operative Directors Surgeon in Chief & individual surgeons ACTION Service reports ICC, SMC, MAC Board-Balanced Score Card Recommendations for altering any processes
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 (36-38 0 C)
SSI Surveillance Methods Inpatient SSI Surveillance MDT Rounds M&M Rounds Microbiology Reports Daily Admission list Post Discharge SSI Surveillance Post discharge Surveillance form
SSI Risk Stratification Predictors of SSI Risk Host susceptibility-asa score Degree of microbial contamination of surgical site Duration of operation
SSI Risk Stratification-cont d NNIS 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 incisionalskin 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 Rates Numerator Definition Number of clean surgery patients (wound class I & II) having a post operative wound infection Denominator Definition Number of clean surgery patients (wound class I & II) Exclusion Criteria Patients < 18 years of age Surgeries classified as wound class III & IV SSI Rate = Numerator x 100 Denominator
Percentage of Colorectal Surgery Patients with Antibiotic Administration Within 60 minutes Prior to Surgical Incision Percent of Surgical Patients with Antibiotic Administration Within 60 minutes Prior to Surgical Incision for Colon Surgery Percenatge 12 0 10 0 80 60 40 20 0 SHN Target=95% 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 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 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 Months
Percentage of Colorectal Surgery Patients with Normothermia in PACU (36-38) Percent Colon Surgery Patients with Normothermia in PACU Percentage 100 80 60 40 20 0 SHN Target=95% 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 Apr-06 May- Jun-06 Jul-06 Aug- Sep- Oct- Nov- Dec- Jan-07 Feb- Mar- Apr-07 May- Jun-07 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 Months THE LANCET Vol 358: Sept 15, 2001 THE NEW ENGLAND JOURNAL OF MEDICINE Vol 334, No 19, 1996
Percentage Return Rate of Post Discharge Surveillance Forms Percentage 60 50 40 30 20 10 0 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 Jul-06 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul-07 Aug- 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 Months 53% Returns from our own Surgeons 19% of returned forms reported an infection Between 12% and 84% of SSI are detected after patients are discharged from the hospital Infection Control and hospital Epidemiology Apr 1999; 20,4250-269
Challenges Wound Classification Assign 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 needs CDC Recommendation Category II
Challenges-cont d Breakdowns in delivery of Post Discharge Surveillance Form Placement in the chart Correct placement in the chart Delivery and proper instructions by RN Patient bringing the form to Surgeon/GP Surgeon/GP sending the form back to us Don t seem to have any control over last 2 factors
Preventing Surgical Site Infection Four Components of Care PLAN ACT DO Appropriate Hair Removal STUDY Appropriate Use of Prophylactic antibiotics Maintenance of Post Operative Glucose Control Peri Operative Normothermia (Colorectal Surgeries)
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