SURGICAL SITE INFECTION SURVEILLANCE Training for data management, quality assurance and reporting

1. Scottish Surveillance of Healthcare Associated Infection Programme SURGICAL SITE INFECTION SURVEILLANCE Training for data management, quality assurance and reporting

2. Role of HPS Scottish Surveillance of Healthcare Associated Infection Programme • To co-ordinate, facilitate and support the implementation of SSI surveillance • To prepare Protocols • To prepare data collection tools • To support on-going data management and ensure quality data • To collate and report the national data set

3. Objectives: Scottish Surveillance of Healthcare Associated Infection Programme • To describe and apply all data management points pertinent to the local and national management of data • To apply quality assurance requirements to SSI surveillance data • To develop reporting and mechanisms of feedback for surgical site infection data

4. Introduction to Surveillance • Surveillance is the ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The final link of the surveillance chain is the application of these data to prevention and control. (Centers for Disease Control and Prevention 1988)

5. Objectives of surveillance • Early warninginvestigation of problems and intervention to control • Monitoring trends • Examining impact of interventions • To gain information on quality of care • Targeting resources

6. Scottish SSI Surveillance Programme- The Surveillance Cycle

7. Data collection completed at site Data are sent to the local surveillance coordinator Data are quality checked and anonymised (Patient identifying details removed) Data are sent to local nominated data transfer coordinator (if required) Electronic data transfer to HPS* Forms sent to HPS by post or fax* Results fed back to hospitals Collated for national reporting of SSI surveillance Data scanned at HPS and database with reporting facilities fedback to hospital within 3 months National Report

8. Scottish Surveillance of Healthcare Associated Infection Programme SURGICAL SITE INFECTION SURVEILLANCE Data Management

9. Aims of SSIS Programme Scottish Surveillance of Healthcare Associated Infection Programme • Collect surveillance data on SSI’s to permit estimation of the magnitude of SSI risks in hospitalised patients • Analyse and report SSI surveillance data and describe trends in infection rates • Provide timely feedback of SSI rates to assist surgical units in minimising the occurrence of SSI’s

10. Data Management

11. Each Division should undertake surveillance on at least two of the following operation categories, hip arthroplasty & caesarean section must be undertaken if performed at site. What data? Scottish Surveillance of Healthcare Associated Infection Programme Generic Cardiac Surgery, CABG, Abdominal Hysterectomy, Caesarean Section, Major Vascular Surgery, Breast Surgery, Cranial Surgery. Orthopaedic Hip Replacement, Operations for Fractured Neck of Femur, Knee Replacement.

12. Data Management Process Data Collection Checking for Completeness and Accuracy Data Input Quality Assurance Checking ‘Local’ Reporting ‘National’ Reporting

13. Alternative Data Management Scenarios Scottish Surveillance of Healthcare Associated Infection Programme • ‘Local’ Data Management • Data Management at HPS • Data Transfer • The SSIS Database

14. Quality Assurance Workshop Scottish Surveillance of Healthcare Associated Infection Programme • Collect completed forms • Check forms for completeness and accuracy • Process the data into the database • Carry out QA Checking • Present your findings

15. Scottish Surveillance of Healthcare Associated Infection Programme SURGICAL SITE INFECTION SURVEILLANCE Ensuring valid and reliable data through quality checks

16. AIM Scottish Surveillance of Healthcare Associated Infection Programme • To promote valid and reliable data by performing thorough and appropriate quality checks

17. Objectives: Scottish Surveillance of Healthcare Associated Infection Programme • To recognise the importance of appropriate data quality checks – both locally and nationally • To understand how to perform quality checks on different aspects of data entry • To be aware of the consequences of poor quality data

18. A quality product is important to us all, SSI surveillance data is no different A lot of time and effort is put in by many people towards SSI surveillance data to ensure it is: Valid Reliable Everyone must have confidence in the data – that what is presented is a quality product ! What would you look for in a quality product?

19. Unreliable, invalid and subsequently inaccurate data Subjective outcome(s) Waste of time ! Consequences of poor quality data

20. Consequences of poor quality data • Overestimated infection rates • Underestimated infection rates • Inappropriate change to evidence based practice • No change to practice / infection rates !

21. Implications for Divisions • Clinical Governance Agenda • Quality Improvement Standards (CSBS) • Performance Assessment Framework • National Reporting • Public Concern

22. The “5 Ws” for quality • What – SSI surveillance data • Who – local and national teams • When – frequency of data collection,collation and feedback • Where – local and national teams • Why – to ensure valid and reliable data

23. Quality checks • Manual/visual checks • Automated Form Processing • Standard queries within Microsoft Access database

24. What Who When Where Why Data collection forms returned for collation to local co-ordinator Forms visually checked for: Completeness Accuracy Cleaning of data Locating missing data Perform at least monthly, to avoid backlog Denominator checks also performed at this time, e.g. through theatre lists Essential to ensure data are accurate before sending to HPS and compiling reports for local feedback Manual/visual quality checks

25. Manual / visual quality checks • What • Who • When • Where • Why • Forms are received by SSHAIP team (HPS) from divisions (monthly) • QA protocol is followed - forms are checked for: • Completeness • Accuracy • Cleaning of data • Locating missing data

26. AFP quality checks • What • Who • When • Where • Why • Forms scanned (within the quarter) • ‘Validation rules’ (within Teleform) • Locating missing data • Verification of fields prompted • SSHAIP team verify queries • 1st 100 forms verified field by field to be confident in level of accuracy • Thereafter, monthly 10% of forms randomly checked field by field

27. Validation Rules • Entries required • Date frames set, e.g. age, date of admission, date of operation • Time frames set, e.g. start time of operation, completion time of operation, date of confirmed SSI

28. Standard queries written include: Lookup tables, e.g. hospital codes, OPCS4 codes ‘Value’ checks, e.g. sex, category of procedure Date, time and value frames set, e.g. date of operation, BMI Accuracy checks, e.g. criteria for SSI and when SSI detected - against SSI present and date frames Queries run and verified (e.g.monthly) by SSHAIP team Anomalies checked, contact with local co-ordinator • What • Who • When • Where • Why MS Access Standard Query - Quality Checks

29. Annual case note review 20 random case notes reviewed against database SSHAIP team and local co-ordinators Permission for access A report will be fedback to all divisions Denominator checks In addition to division denominator checks the SSHAIP team will liaise with ISD to obtain denominators by hospital by procedure • What • Who • When • Where • Why Additional QA checks

30. Summary • The importance of understanding: • The processes for data entry • The many data quality checks • The responsibilities for quality checks, both locally and nationally • The consequences of poor quality data

31. Data Reporting Workshop • Workshops to: • Be familiar with reports that can be obtained through MS Access database • Consider use of these reports for the local feedback process • Raise any issues with these reports • Analyse reports to ensure they provide valid and reliable data

32. Reporting data

33. Reporting of data Objectives: • To develop an understanding of the local and national mechanisms of reporting SSI data • To describe risk adjusted reporting • To examine the different mechanisms which can be utilised for reporting data

34. Reporting ?

35. Requirements for successful surveillance • Commitment of senior managers • Commitment of a multidisciplinary staff • A suitable method for data collection • A suitable method for reporting

37. The “5 Ws” of data reporting • What ? • Who ? • When ? • Where ? • Why ?

38. What ? – Feedback of data • Graphs • Tables • Descriptive statistics • Inferential statistics

39. What ?Risk Index for SSI Surveillance • SSI rates, by surgical procedure/category, which will be stratified by risk index. • The NNIS risk index will be used for this. • This index scores each procedure according to the presence or absence of three risk factors at the time of surgery and scores range from 0 (none of the factors present) to 3 (all of the factors present). The risk factors are: • ASA score>=3 • Wound classified as contaminated or dirty • Duration of operation

40. EXIT NNIS Risk Index Graph

41. Who? – Presenting the data • All stakeholders: All multidisciplinary involved in the surgical care pathway • Surgeons • Infection control staff • Managers/ resources • HPS

42. Regular feedback: Active Passive Denominator At least quarterly Locally: by individual (anonymised) Nationally: HPS collate and present by Division When ? Where ?

43. Why ? • Prevention (Haley et al) • Engaged clinicians • Motivated Infection control staff • Intensive surveillance programme • Hawthorne effect • Early identification of problem trends/ outbreaks • Resource allocation

47. Wound surveillance nurse identifies patients from theatre lists Wound surveillance nurse administrates the project Daily visits to all surgical wards to carry out wound checks Operative details…completed by wound surveillance nurse on the ward post op Demographic details…completed by wound surveillance nurse on the ward pre-op Patients have a 24 hour answer service telephone number to call with wound problems. Primary care staff also liaise with wound surveillance nurse Patients with identified wound problems are seen at wound surveillance clinics, or at home by the wound surveillance nurse for wound review Wounds are checked before discharge from hospital Patients are seen at wound surveillance clinics, or at home by the wound surveillance nurse at day 30 post-op for wound review Data are graphed and fed back to the surgeons, nurses and infection control team on a monthly basis Data are managed and collated by the wound surveillance nurse

48. Conclusion • SSI rates are key quality indicators for surgery • Data must be complete • Data must be reliable and valid • Data must be reported back to clinicians • Data must be acted upon

49. Summary • Overviewed data management issues pertinent to the local and national management of data • Developed an understanding of the local and national quality assurance requirements • Aware of the importance of reporting and mechanisms of feedback of surgical site infection data

50. www.hps.scot.nhs.uk