SURGICAL SITE INFECTION SURVEILLANCE Training to ensure valid and reliable surveillance data

1. Scottish Surveillance of Healthcare Associated Infection Programme SURGICAL SITE INFECTION SURVEILLANCE Training to ensure valid and reliable surveillance data

2. Why are we here? • National SSI surveillance in Scotland • Establishing the impact of HAI in Scotland • HDL (2001) 57 • All acute Divisions must do surveillance of 2 surgical procedures, 1 of which should be orthopaedic

3. HDL (2006)38 • Hip arthroplasty surveillance mandatory from Jan 2007 if procedure performed within hospital • Readmission surveillance must be undertaken for this category until day 30 post op • Caesarean section surveillance mandatory from Jan 2007 • PDS must be undertaken to day 30 post all for all c section procedures

4. Surveillance is: • Policing! • A survey • Research • Audit

5. HPS’s Role 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

6. Public awareness! Quality is at the heart of everyone’s agenda Clinical Governance Clinical Standards Accountability Reviews Performance Assessment Framework Today’s climate and demands!

7. HAI - Extent of the problem • 100, 000 patients affected per year • 5000 deaths per year

8. The Cost of HAI

10. AIM Scottish Surveillance of Healthcare Associated Infection Programme • To promote accurate completion of surgical site infection surveillance forms

11. Learning Objectives Scottish Surveillance of Healthcare Associated Infection Programme • To recognise the benefits of surveillance in relation to surgical site infection (SSI) • To describe the background to SSI surveillance • To discuss the importance of data definitions • To evaluate the variety of processes that can be utilised to carry out SSI surveillance

12. 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)

13. Introduction to Surveillance • The objectives of healthcare associated infection (HAI) surveillance are to: • Monitor the incidence of HAI, including SSI • Provide early warning and investigation of problems and subsequent planning and intervention to control • Monitor trends, including the detection of outbreaks • Examine and share the impact of interventions • Gain information on the quality of care • Prioritise the allocation of resources

14. Introduction to Surveillance • Surveillance is a multidisciplinary activity and local ownership is crucial • National surveillance should be a by-product of local surveillance • Local feedback is essential

15. HAI Proportion of Proportion of Proportion of Proportion all HAI extra bed extra cost preventable? (%) days(%) (%) (%) UTI 45 11 13 38 SSI 29 57 42 35 Pneumonia 19 39 Sur 27; Med13 24 Bloodstream 2 4 3 35 Other 6 4 3 N/A Source: Haley 1995 and 1985 • HAICost (£pp)Nat Burden*(£M) • SWI 3246 62.37 • in-patient only • Source: Plowman et al. Socio-Economic Burden of HAI

16. Specific operation categories known to have unacceptably high infection rates Many factors have been recognised that influence the occurrence of SSI Pre operative Intra operative Post operative Surveillance can result in a reduced infection rates but is unlikely to be the only factor: ICTs Commitment of all staff Education on risk factors/evidence based practice Adequate staffing, resources, equipment Is there a Hawthorne effect? Background to SSI surveillance – What is the problem?

17. Background to SSI Surveillance • SSI is therefore important as it continues to be a key complication of surgery, with high human and financial costs • The potential to improve infection rates through surveillance has been proven • A number of other programmes are already in place: • NNIS • SSISS • PAN CELTIC • Local projects • In Scotland: SSHAIP

18. SSI Surveillance Protocol and Resource Pack HAI Surveillance newsletter to share good practice Communications and visits with all divisions Updates to National Steering Group Training for those involved………… Scottish SSI Surveillance Programme – the way forward……

19. Operation Categories for SSI Surveillance • Orthopaedic: hip replacement, knee replacement, operations for fractured neck of femur • Cardiac: CABG, other cardiac surgery • General: breast, major vascular • Obs/Gyn: abdo hysterectomy, c.section • Cranial Surgery

20. PATIENT PATHWAYS FOR SSI SURVEILLANCE TO POST OP DAY 30 Admission Death Operation Post Operative In-patient Discharge Transfer Death Re-operation In-patient to day 30 Post Discharge Surveillance Re-admission PDS to day 30 In - patient end of Surveillance End of Surveillance

21. Decide on operation categories for surveillance Identify multidisciplinary personnel to be involved in the local surveillance team Hold surveillance team meetings to discuss logistics of the programme. Discuss forms, definitions, dataset, start date etc.* Ensure key personnel are prepared and all systems are in place to commence the surveillance Hold training sessions for key personnel to include SSI definitions and data management* Produce local guidance and make forms, posters and flowcharts available in key areas *The SSHAIP team at HPS should be involved at these stages Pilot and launch the programme

22. Project officer administrates the surveillance All forms are uniquely identified and originate in theatre Anaesthetist completes questions in theatre Surgeon completes questions in theatre Theatre nurses complete questions on the form ICN contacted when SSI present and completes questions Form is transferred to ward with patient Ward nurses complete questions Ward clerk returns forms to the project officer (Infection Control department) when the patient is discharged IC Dept provides local feedback Project officer manages the data and transfers this to HPS

24. 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

25. 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) Forms sent to HPS by post Electronic data transfer to HPS* 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 Pan Celtic Collaboration National Report IPSE

26. Essential Elements of a Successful HAI surveillance system • Defining what outcomes to measure • Ensuring everyone involved is aware of the outcomes • Reliably collecting the data in a standardised/defined manner • Analysing data for comparison • Using the data locally in a timely manner to improve quality of care Gaynes & Solomon. J Quality Improvement 1996;22:457-67

27. In Summary • Recognise the benefits of and the background to conducting SSI Surveillance • Understand and apply to your setting the various processes that can be utilised to conduct SSI Surveillance

28. AIM Scottish Surveillance of Healthcare Associated Infection Programme • To promote accurate completion of surgical site infection surveillance forms

29. Learning outcomes Scottish Surveillance of Healthcare Associated Infection Programme • To define the categories that are included in diagnosing SSIs • To describe and discuss the appearance of surgical sites, to include the aforementioned categories • To explain the surveillance form completion process

32. Definitions of SSI Superficial SSI (Incisional) • A superficial SSI must meet the following criterion: • Infection occurs within 30 days after the operative procedure • And involves only skin and subcutaneous tissue of the incision • And patient has at least one of the following: • Purulent discharge from the superficial incision • Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision • At least one of the following signs or symptoms of infection: pain or tenderness, localised swelling, redness, or heat and superficial incision is deliberately opened by surgeon unless incision is culture negative • Diagnosis of superficial incisional SSI by surgeon or trained healthcare worker* (* Trained healthcare worker is defined as a qualified doctor or nurse who has been trained in the national definitions of SSIs.)

34. Definitions of SSI Superficial SSI (Incisional) • The following are not reported as superficial incisional SSI: • Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration) • Infected burn wound e.g. diathermy • Incisional SSI that extends into the fascial and muscle layers (deep incisional SSI)

36. Definitions of SSI Deep SSI (Incisional) • A deep incisional SSI must meet the following criterion: 1. Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure 2. And involves deep soft tissues (e.g. fascial and muscle layers) of the incision

37. Definitions of SSI Deep SSI (Incisional) 3. And patient has at least one of the following: • Purulent discharge from the deep incision but not from the organ/space component of a surgical site • A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (>38oC) or localised pain or tenderness, unless incision is culture negative • An abscess or other evidence of infection involving the deep incision is found on direct examination, during re-operation, or by histopathological or radiological examination • Diagnosis of a deep incisional SSI by surgeon or trained healthcare worker

39. Definitions of SSI Organ/Space SSI • An organ/space SSI involves any part of the body, excluding the skin incision, fascia, or muscle layers that is opened or manipulated during the operative procedure. Specific sites are assigned to organ/space SSI to further identify the location of the infection. An example is an appendicectomy with subsequent diaphragmatic abscess, which would be reported as an organ/ space SSI at the intra-abdominal specific site.

40. Definitions of SSI Organ/Space SSI • An organ/space SSI must meet the following criterion: • Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure • And infection involves any part of the body, excluding the skin incision, fascia, or muscle layers that is opened or manipulated during the operative procedure

41. Definitions of SSI Organ/Space SSI 3. And at least one of the following: • Purulent discharge from a drain that is placed through a stab wound into the organ/space • Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space • An abscess or other evidence of infection involving the organ/space that is found on direct examination, during re operation, or be histopathological or radiological examination • Diagnosis of an organ/space SSI by surgeon or trained healthcare worker

42. Vascular: Arterial or venous Breast: Breast abscess Mastitis Orthopaedic: Joint or bursa Osteomylitis Abdominal Hysterectomy: Intraabdominal Endometritis Vaginal Cuff Ovaries, uterus, pelvic cavity C. Section: Endometritis Ovaries, uterus, pelvic cavity Organ/Space SSI

43. Criteria Used to Determine SSI – Surveillance Form (generic) • Purulent drainage • Organisms isolated from an aseptically obtained culture of fluid or tissue • Abscess/other evidence found on direct examination, during a re-operation or radiology/histopathology • Incision spontaneously dehisces • Incision is deliberately opened by surgeon • Fever (temperature 38 degrees or more) • Localised pain or tenderness • Localised swelling • Redness • Heat • Diagnosis by surgeon or trained healthcare worker

44. Vascular: Organisms not isolated from blood/ blood culture not done Orthopaedic: Limitation of motion Evidence of effusion Organisms and WBC seen on gram stain of joint fluid Positive antigen test on blood, urine or joint fluid Cellular profile and chemistries of joint fluid compatible with infection NB: No extra criteria for breast Various extra criteria for cardiac/ CABG (See SSI protocol) Abdominal Hysterectomy/ C.Section: Nausea Dysuria Vomiting Organisms seen on gram stain Extra criteria for organ/ space infection

45. Cellulitis Delayed healing Discolouration Friable granulation tissue, which bleeds easily Pocketing at the base of the wound Bridging within the wound Odour 105 colony forming units per gram of tissue Other definitions of wound infections

47. Common organisms found to cause SSIs: Staphylococcus aureus Coagulase-negative staphylococci Gram negative bacilli Anaerobes group B streptococci These can be endogenous flora Exogenous flora are also common and avoidable Surgical site culturing Why are you sampling? When are you sampling? What are you sampling? How are you sampling? Labelling and lab form completion Interpreting results from the lab Surgical site microbiology

48. 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

49. Background to SSI Surveillance – Wound Classes • Surgical wounds can be classified according to the likelihood and degree of wound contamination at the time of operation. • The wound classification used for this surveillance is based on that developed be the National Research Council in the USA.

50. Wound Classes • Clean • Clean contaminated • Contaminated • Dirty or infected