1. NHSN SSI Clarifications Janet Sullivan, Oregon SW Washington APIC Jeanne Negley, Oregon Health Policy & Research

2. Addressing some NHSN Definitions Recording multiple procedures – Recording denominators – Assigning infections – Determining duration cut point – Addressing issue reporting for state required measures and those recorded for the hospital’s own use Closure of the incision Schedule for next HAI report

3. Multiple Procedures through the same incision Two characters: – Sally State: only reports state required measures – Robert Reportall: reports state measures and additional procedures Assumption: all procedures presented below are NHSN procedures (defined by ICD-9 codes in Table 1 of Chapter 9, NHSN SSI protocol). Scenario: inpatient small bowel, colon, and rectal NHSN procedure performed through a single incision during a single trip to the OR.

4. Multiple Procedures through the same incision Question 1: What procedures (denominators) do I report in NHSN? – Sally State: COLO – Robert Reportall: COLO, REC, SB Question 2: What if an infection is identified? – Sally State: 1. When multiple procedures through the same incision, first attempt to determine which procedure is responsible for SSI. 2. If it is clear the COLO procedure is responsible, report it to NHSN. (Infection will be reported to state.) 3. If it is unclear (you are not able to determine) which procedure is responsible for the SSI, assign it to the highest surgical code in the priority table. 4. If the infection is assigned to REC or SB, do not report the infection to NHSN. 5. Option: use NHSN optional field to record that infection was assigned to REC or Priority List used to assign to SB.

5. Multiple Procedures through the same incision Question 2: What if an infection is identified? – Robert Reportall: 1. When multiple procedures through the same incision, first attempt to determine which procedure is responsible for SSI. 2. If it is clear the COLO procedure is responsible, report it to NHSN. (Infection will be reported to state.) 3. If it is clear REC or SB procedure is responsible, report to NHSN. (Infection not reported to state.) 4. If it is unclear (you are not able to determine) which procedure is responsible for the SSI, assign it to the highest surgical code in the priority table. 5. Option: use NHSN optional field to record that infection was assigned to REC or Priority List used to assign to SB.

6. The NHSN “Priorities List” Table 3 of Chapter 9 of NHSN Protocol, Procedure Associated Events SSI

7. Multiple Procedures through the same incision Question 3: If we record multiple procedures doesn’t that inflate the colon procedure, since with the Priority Lists many SSIs would be attributed to the small bowel? – It does increase the probability that an infection will be attributed to the small bowel (i.e., the more infections attributed to small bowel, the higher it stays on the Priorities Lists). NHSN does periodically review the list with surgeons, just to make sure the priorities are appropriate, but we are aware of this issue. Question 4: If we are recording multiple procedures through one incision, how do we record duration cut point for the multiple procedures? – The duration cut point represents the actual amount of time that the surgical site (which is basically the same for both) is open and at risk for infection. Therefore, if you conduct a COLO, RB, and SB procedure for 3 hr and 10 minutes, you would record each procedure for 3 hr and 10 minutes

8. Multiple Procedures through the same incision Question 5: How is recording of duration cut point different for CBGB and KPRO bilateral knees? – For bilateral procedures (e.g., KPRO), two separate Denominator for Procedure are completed. To document the duration of the procedure, indicate the incision time to closure time for each procedure separately, or alternatively, take the total time for both procedures and split it evenly between the two. – For CBGB, record the time from skin incision to primary closure. (see pages 9-12 to 9-13 of Chapter 9 of the NHSN Manual).

9. Closure of the Incision An NHSN Operative Procedure is a procedure 1) this is performed on a patient who is an NHSN inpatient or an NHSN outpatient; and 2) takes place during an operation (defined as a single trip to the operating room (OR) where a surgeon makes at least one incision through the skin or mucous membrane; including laparoscopic approach and closes the incision before the patient leaves the OR; and 3) that is included in Table 1.

10. Further Clarification on “closing the incision” If the incision is not entirely closed at the procedure’s end (e.g., if wires or tubes extrude though the incision) then the procedure does not meet the criteria of an NSHN operative procedure. Some examples follow. – If a drain is placed within the surgical incision, this procedure WILL NOT be counted as an NHSN procedure. If the surgical drain is placed via stab wound and is not enclosed in the surgical incision, this procedure will meet criteria as meeting an NHSN procedure. – It is standard procedure to place drains in stab wounds.

11. Further Clarification on “closing the incision” (part 2) MORE EXAMPLES – The insertion of pacer wires in the incision for open heart surgery can also affect whether a procedure meets the criteria as an NHSN procedure. If your facility inserts pacer wires through the mediastinal incision after open heart surgery, it would not allow your surgery to be included as surgical procedures within NHSN. If the pacer wires are brought through another skin site, not from within the surgical incision, then it can be included as an NHSN procedure. – It is standard procedure to have pacer wires extrude through alternative skin sites, NOT in the surgical incision. – We understand that some facilities may have a large volume of colon surgeries, and it may not be possible for IPs to check every surgery report to determine if the surgery was closed. In these circumstances, we recommend that the IP review the surgery reports for all surgeries with Type 4 wound classes (i.e., wounds that are classified as dirty/infected).

12. Will the incision be closed? Photo source: NY State HAI Reporting Program Yes, drain extrudes from stab wound.

13. Will the incision be closed? Photo source: NY State HAI Reporting Program Yes, drain is inserted in surgical incision and exits stab wound. Suture of primary incision will NOT be around drain line.

14. Conclusions: closure of incision Drains are routinely placed in stab wound adjacent to surgical incision. Pacer wires for CBGB routinely extrude from adjacent skin sites (not surgical incision). No need to check surgery reports for all surgeries. Recommend checking surgery reports for wound class 4 (dirty/infected).

15. Schedule for Next HAI Report February 14, 2011, OHPR will pull data set for next report. – All data through December 31, 2010. – NHSN Annual Survey. – Any corrections you have to your data set to 2009 and 2010. CLABSI validation updates. Additional findings from your data review efforts. Communication appreciated. Input on additional training needs? – Wound classification

16. Questions? Jeanne Negley Office for Oregon Health Policy & Research 503-373-1793 Jeanne.Negley@state.or.us http://www.oregon.gov/OHPPR/ Healthcare_Acquired_infections.shtml

17. Adding an Optional Field to Procedure Form Add a custom field to your NHSN procedure form. Facility  Customize Forms  Form Type  CDC- Defined—PS—Patient Safety, Form Type: COLO. In the section Alphanumeric/Label 1, you can input “infection note.” “Save.” Save. Go into COLO procedure form, you will see field where you can type in a 16-character note.

18. Adding an Optional Field to Procedure Form--example