1. SURGICAL SITE INFECTION SURVEILLANCE
STANLEY OSTRAWSKI, MS, RN, MT(ASCP), CIC
Infection Preventionist Consultant 1

2. Objectives Explain how to calculate an SSI rate
Explain how to complete NHSN SSI forms using CDC definitions and protocols
Apply case definitions of procedure-associated infections to case studies

4. Choosing Procedures to Monitor
High Volume
Requirements
High Risk

5. Sample 12 month Surveillance Plan Timeline
Jan
CLABSI
SSI - HPRO
Surgical ABX Prophylaxis
HCW Influenza Vaccine
Feb
SSI - KPRO
Mar
Apr
May
Jun
Sample 12 month Surveillance Plan Timeline
Jul
CLABSI
SSI - HPRO
Surgical ABX Prophylaxis
Aug
SSI - KPRO
Sep
Oct
HCW Influenza Vaccine
Nov
Dec

7. Denominator for Procedure
The reporting period is one month
Collect a procedure record for every procedure that was done during that month
For example, if you plan to monitor KPRO procedures in July and 43 KPRO operations are done in July, then you should collect details with risk factor data on each of the 43 cases.

10. Terms and Definitions
The data you report must use exactly the same terms and definitions
Inpatient
Outpatient
Operative Procedure
Operating Room
Additional terms will be added as we specifically discuss SSI and PPP

11. Definition: Inpatient
A patient whose date of admission to the healthcare facility and the date of discharge are different calendar days.

12. Definition: Outpatient
A patient whose date of admission to the healthcare facility and the date of discharge are the same day

13. Definition: Operative Procedure
A procedure that
is performed on a patient who is an inpatient or an outpatient
takes place during an operation where a surgeon makes a skin or mucous membrane incision (including the laparoscopic approach) and primarily closes the incision before the patient leaves the operating room
is represented by an Operative Procedure Code

14. NHSN Operative Procedure Codes
Each NHSN operative procedure category is defined by a group of ICD-9-CM codes

15. NHSN Operative Procedures
When an NHSN Operative Procedure is selected for monitoring, all the procedures within that category must be followed

16. CBGC -- Coronary artery bypass graft with only a chest incision (mammary donor site)
CBGB – Coronary artery bypass graft with two incisions – chest incision and donor site (usually leg)
These procedures are mutually exclusive for a single trip to the OR.
A patient can never have both!
Important
Note!

17. Definition: Operating Room
A patient care area that meets the American Institute of Architects (AIA) criteria for an operating room
May include:
Traditional operating room
C-section room
Interventional radiology room
Cardiac cath lab

18. Duration
Duration:
Record the hours and minutes between the skin incision and skin closure.
Do not record anesthesia time!

19. Additional Rules about Duration
If more than one NHSN operative procedure is done through the same incision during the same trip to the OR, create a record for each procedure and use the total time for the duration of both
Example: Mr. Jones goes to the OR and has a coronary artery bypass graft with a [leg] donor site (CBGB) and also a mitral valve replacement (CARD). The time from the first incision until skin closure is 5 hours. A Denominator for Procedure record is completed for the CBGB and another for the CARD. The duration for each is recorded as 5 hours and 0 minutes.

20. Additional Rules about Duration
If the patient goes to the OR more than once during the same admission and another procedure is performed through the same incision within 24 hours of the original incision, report the combined duration of operation for both procedures
Example: Fred Smith had a small bowel resection done on Tuesday morning which had a duration of 3 hours and 10 minutes. On Tuesday evening, he was returned to the OR where an exploratory laparotomy (XLAP) was done through the same incision to repair a leaking anastamosis. The XLAP cut time was 1 hour and 10 minutes.
The Duration for each procedure – SB and XLAP -- is reported as 4 hours and 20 minutes

21. Wound Class
Wound class is an assessment of the likelihood and degree of contamination of a surgical wound at the time of the operation
C = Clean
CC = Clean Contaminated
CO = Contaminated
D = Dirty

22. Wound Class Clean Clean-Contaminated
Uninfected wound with no inflammation
Respiratory, alimentary, genital or uninfected urinary tract are not entered
Primarily closed
Closed drainage, if needed
Clean-Contaminated
Respiratory, alimentary, genital, or urinary tracts entered under controlled conditions and without unusual contamination
Include operations on biliary tract, appendix, vagina, oropharynx if no evidence of infection or major break in technique

23. Wound Class Contaminated Dirty Open, fresh, accidental wounds
Major breaks in sterile technique or gross spillage from the GI tract
Includes incisions into acute, nonpurulent inflamed tissues
Dirty
Old traumatic wounds with retained devitalized tissue
Wounds involving existing clinical infection or perforated viscera

24. Wound Class Cases 3 2 4 Case Wound Class
Susanne undergoes an appendectomy following 2 days of acute abdominal pain with rebound tenderness. At the end of the case, the surgeon indicates that the appendix had ruptured and the surgical area was irrigated and keflex was ordered for 3 days postoperatively.
Fred has a cholecystectomy using a laparoscopic technique. The gallbladder was removed successfully with no breaks in operative asepsis.
George has a KPRO revision. When the surgeon makes the incision into the surgical site, she notes that the knee joint demonstrates purulent matter and inflammation. A specimen is obtained and sent to the laboratory which grows S. aureus (MSSA). 3 2 4

25. ASA Class
An assessment score by the anesthesiologist of the patient’s preoperative physical condition using the American Society of Anesthesiologists Classification of Physical Status schema
Normally healthy patient
Patient with mild systemic disease
Patient with severe systemic disease that is not incapacitating
Patient with an incapacitating systemic disease that is a constant threat to life
Moribund patient who is not expected to survive for 24 hours with or without operation

26. Implant
Implant: A nonhuman-derived object, material, or tissue that is permanently placed in a patient during an operative procedure and is not routinely manipulated for diagnostic or therapeutic purposes. Examples include: porcine or synthetic heart valves, mechanical heart, metal rods, mesh, sternal wires, screws, cements, and other devices. Also includes surgical clips and staples left in permanently.

27. Yes No Ella Baxter underwent a CBGB
(coronary artery bypass graft with a leg donor site). During the same operation, she had a mitral valve replacement (CARD)with a porcine valve.
Did Ms. Baxter’s procedure include an implant?
Yes
Did Ms. Baxter’s procedure include a transplant? No

28. Surgical Site Infection (SSI)

29. Introduction
SSI occurs in 2 – 5% of patients undergoing inpatient surgery in the U.S.
Approximately 500,000 each year
Each SSI is associated with approximately 7-10 additional postoperative hospital days
Attributable cost estimates of SSI range from $3,000 - $29,000 each

30. Minimum SSI Surveillance
Review of patient and laboratory records during the patient admission
Review of surgical patient readmissions
Microbiology data from postoperative wound cultures

31. SSI Post-discharge Surveillance
The definition of the specific SSI must be met for any methodology used!
Post-discharge surveillance methods may also include:
Examination of patient surgical site during follow-up visits to physician office or surgery clinic
Surgeon surveys by mail or phone
Review of medical records for postoperative visits

32. Superficial Incisional
SSI Definitions
Superficial Incisional
SIP
SIS
Deep Incisional
DIP
DIS
Organ/Space
BONE
BRST
CARD
DISC
EAR
EMET
ENDO
etc.

33. Superficial Incisional SSI
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13(10):606-8.

34. Superficial Incisional SSI

35. SIP and SIS Superficial incisional primary (SIP)
A superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for coronary artery bypass graft with a donor site [CBGB])
Superficial incisional secondary (SIS)
A superficial incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site [leg] incision for coronary artery bypass graft with a donor site [CBGB])

36. Example
Gretchen Dale delivers a baby by C-Section on August 23. On her 2-week postpartum visit to her surgeon, she notes yellow purulent drainage in the superficial incision.
Does Gretchen have a surgical site infection?
Yes
Yes
Is it a superficial SSI?
SIP
Is it an SIP or an SIS?

37. Deep Incisional SSI
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13(10):606-8.

38. Deep Incisional SSI

39. Deep incisional primary (DIP) Deep incisional secondary (DIS)
DIP and DIS
Deep incisional primary (DIP)
A deep incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for coronary artery bypass graft with a donor site [CBGB])
Deep incisional secondary (DIS)
A deep incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site [leg] incision for coronary artery bypass graft with a donor site [CBGB])

40. Examples
Charles has purulent drainage from the chest incision following a coronary artery bypass graft with a donor site from the left leg. He also has redness and pain at the leg incision. The doctor opens and drains the incision. No culture is done for either site.
How should this be reported to NHSN?
SIP
SIS
Both
Neither

41. Organ/Space SSI
BONE
Osteomyelitis
JNT
Joint or bursa
BRST
Breast abscess/mastitis
LUNG
Other infections of respiratory tract
CARD
Myocarditis/
pericarditis
MED
Mediastinitis
DISC
Disc space
ORAL
Oral cavity
EAR
Ear, mastoid
OREP
Other respiratory
EMET
Endometritis
OUTI
Other urinary
ENDO
Endocarditis SA
Spinal abscess
EYE
Eye, other than conjunctivitis
SINU
Sinusitis
GIT
GI tract UR
Upper respiratory
IAB
Intraabdominal, NOS
VASC
Arterial or venous IC
Intracranial
VCUF
Vaginal cuff
Specific event types that must be used to differentiate organ/space SSI

42. Organ/Space SSI

44. When a patient with an SSI has had more than one operation…
If a patient has several NHSN operations prior to an SSI, report the operation that was performed most closely in time to the infection date
Example: Mr. Smith underwent a SB on 12/02/ Three days later, he went back to surgery to repair a leaking anastamosis (OTH). He developed an intraabdominal abscess on 18/03/ This SSI is attributed to the second procedure (OTH), not the SB

45. Example
Robert Jones undergoes a coronary artery bypass graft (CBGB) in which the surgeon obtained a donor vessel from a site in Robert’s left leg.
5 days postoperatively, Robert had pain and edema in the leg incision. The surgeon opened the superficial incision, drained the pus, and irrigated the wound.
Yes
Does Robert have a superficial incisional SSI?
SIS
Is it a SIS or SIP?

48. SSI – Event Details
Select the specific elements of the definition that were used to identify this infection

51. Secondary BSI
A culture-confirmed BSI associated with a documented HAI at another site
If a primary infection is cultured, the Secondary BSI must yield culture of same organism and exhibit the same antibiogram as the primary HAI site
Example: Mrs. Jones grows E. coli in her urine (>100,000 col/cc) and in her blood. Both organisms have the same antimicrobial susceptibility pattern. The UTI is reported with a secondary BSI.
Example: Mr. Smith grows A. baumanii in his surgical wound which is resistant to amikacin and levofloxin but sensitive to other tested antimicrobials. He is also growing A. baumanii in his blood, but it is susceptible to amikacin.

52. Secondary BSI (cont.)
If an infection is identified and no culture is used to meet the infection criteria and a blood culture is positive, then the first infection is considered primary and the bloodstream infection is reported as secondary. The organism cultured from the blood is reported as the organism for the primary site.
Example: 6 days postoperatively, Miss Green has an abdominal abscess, confirmed by CT scan. On the same day, her blood is drawn and grows Bacteroides fragilis. The infection is reported as an SSI-GIT (organ space SSI) with a secondary BSI. The organism is reported as B. fragilis

53. Does Mr. Fuentes have a secondary BSI?
Mr. Fuentes has a central line for infusion of fluids during a complex abdominal procedure and the blood culture grows Bacteroides fragilis on the 4th postoperative day. His surgeon states that the BSI is secondary to the operation – he says there was probably a small leak in the anastamosis.
Does Mr. Fuentes have a secondary BSI?
Yes, the primary infection is SSI-IAB
Mr. Fuentes has both a CLABSI and an SSI-IAB
Mr. Fuentes has a CLABSI – not secondary to an SSI

54. SSI Rate * Stratify by: Type of NHSN operative procedure
Basic NHSN Risk Index

55. NHSN Basic Risk Index
The index used in NHSN assigns surgical patients into categories based on the presence of three major risk factors:
The patient’s SSI risk category is simply the number of these factors present at the time of the operation

56. Example of NHSN Risk Index
Elements
Patient #1
Patient #2
Patient #3
Operation > duration cut point
Yes No
Wound class IV I II
ASA Score 4 1
Risk Index Category 3

57. 2008 NHSH Report – SSI Rates

58. George Bolthouse, 51
The patient has an aortic aneurysm repair (AAA) surgery and is discharged, then comes back about a week later with peritonitis. A needle aspiration of purulent material from the abdomen grows P. aeruginosa. The surgeon attributes the peritonitis to a perforated diverticulum.
Should this be counted as a surgical site infection associated with the AAA?
Yes – this is an organ/space SSI (IAB)
No, a perforated diverticulum is a complication of the surgery, not an infection

59. Tom Jones, 32
Mr. Jones is a post op hernia (HER) patient that was seen in the ER 6 days post op with a large cellulitis, a pain level 10/10, swelling, tenderness, and redness. He was admitted for treatment with antibiotics. He had leukocytosis and an elevated CRP (199). Serous drainage from the incision was no growth.
Is this a superficial incisional or a deep incisional SSI?
Superficial incisional SSI
Deep incisional SSI
Neither – the surveillance criteria for SSI are not met

60. Bruce Keller Patient underwent a KPRO procedure at our hospital
The patient was discharged to a rehab facility and sustained a fall one week later
The incision dehisced and became infected
Is this an SSI? Should it be reported?
As long as there is no indication that the wound dehisced because it was infected, it would not be reported.

61. Mary Blair, 77
Patient had a hip prosthesis procedure (HPRO) on 2/4/08. She had an infected AV dialysis graft rupture on 7/6/08 – blood cultures grew Staph aureus and she was placed on antimicrobials for treatment of the bloodstream infection. On 7/21/08, Jane experienced pain in the hip joint – radiographic evidence on gallium scan shows an abscess at the hip prosthesis site– culture of hip was no growth.
Should this be counted as a SSI associated with the HPRO if the AV graft was the primary infection and it appears that the hip became seeded secondarily?
Yes, this is an SSI
No, this infection is secondary to the bloodstream infection

62. Question?
Which of the following does not meet the criteria for a superficial incisional SSI if identified within 30 days after the procedure?
Culture of fluid obtained from superficial incision grows MRSA
Physician documents “superficial surgical site infection” in patient record
Purulent drainage noted from superficial incision
Physician documents “cellulitis” at incision site

63. What do you do about high rates?
Share data with surgeons either way (High or Low)
Type of surgery
Same surgeon, OR room, etc
Surveillance methods
Extensive vs minimal.
Look at SCIP measures
Prophylactic ABX
Timing important
Is MRSA a problem?
Are doses weight based?
Look at other pre op measures
Post op measures

64. Questions?