ssi: i hear the words, but are we talking about the same thing? safer healthcare now! western node...
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SSI: I hear the words, SSI: I hear the words, but are we talking about the same thing?but are we talking about the same thing?
Safer Healthcare Now! Western Node
Wendy Runge, RN, BScN, CICWendy Runge, RN, BScN, CIC
Infection Prevention and Control, Infection Prevention and Control,
Calgary Health RegionCalgary Health Region
Surgical Site Infections: Simply Complicated
CDC/NNIS SYSTEMCDC/NNIS SYSTEM
Guideline for Prevention of Guideline for Prevention of Surgical Site Infection, 1999 Surgical Site Infection, 1999 includes:includes:– Definition criteria for inclusion Definition criteria for inclusion
(or not!)(or not!)– Classification of infection Classification of infection
depthdepth
SSI DefinitionsSSI Definitions
Each depth has a set of Each depth has a set of definition criteriadefinition criteria
Each case must meet the Each case must meet the definition criteria definition criteria EXACTLYEXACTLY
Extended surveillance period for Extended surveillance period for implant surgery (12 months)implant surgery (12 months)
CDC/NNIS SYSTEMCDC/NNIS SYSTEM
NNIS reports:NNIS reports:– Criteria for risk stratificationCriteria for risk stratification– Provides risk adjusted Provides risk adjusted
‘Benchmark’ rates for specific ‘Benchmark’ rates for specific proceduresprocedures
NNIS RatesNNIS Rates
Risk- adjusted NISS ‘Benchmark’ Risk- adjusted NISS ‘Benchmark’ infection rate for hip prosthesis:infection rate for hip prosthesis:
0 = 0.54%0 = 0.54%
1 = 1.24%1 = 1.24%
2, 3 = 2.05%2, 3 = 2.05%
(50(50thth percentile rates; taken from the percentile rates; taken from the 1992-2003 NNIS report)1992-2003 NNIS report)
Case Study: Mrs. DCase Study: Mrs. D
73 year old female with IDDM, CAD, 73 year old female with IDDM, CAD, COPD and osteoarthritisCOPD and osteoarthritis
Right total hip performed in Right total hip performed in March/2005March/2005
Operative Details:Operative Details:– Intra operative cultures negIntra operative cultures neg– Procedure took 2:30Procedure took 2:30– PatientPatient ASA score was ‘3’ ASA score was ‘3’
– Wound classification = CleanWound classification = Clean
Case Study: Mrs. DCase Study: Mrs. D
Is Mrs. D a high surgical risk Is Mrs. D a high surgical risk patient?patient?
What is her NNIS risk score?What is her NNIS risk score?
Mrs. D Mrs. D (cont.)(cont.)
Uneventful surgery and hospital Uneventful surgery and hospital recovery, with discharge on day recovery, with discharge on day 66
Wound was ‘well approximated’ Wound was ‘well approximated’ with ‘scant serous discharge’with ‘scant serous discharge’
Does the drainage indicate an Does the drainage indicate an infection?infection?
Mrs. D Mrs. D (cont.)(cont.)
At 14 days post op, Mrs. D At 14 days post op, Mrs. D presents to ER with R hip redness presents to ER with R hip redness and some localized edemaand some localized edema
No drainage noted, no culturesNo drainage noted, no cultures The ER doc diagnoses ‘Cellulitis’ The ER doc diagnoses ‘Cellulitis’
and starts her on a course of and starts her on a course of KeflexKeflex
Is this an infection? Is this an infection?
Mrs. D Mrs. D (cont.)(cont.)
4 weeks post op, Mrs. D presents 4 weeks post op, Mrs. D presents in ER again, this time with hip in ER again, this time with hip pain, fever and an elevated WBCpain, fever and an elevated WBC
She is admitted to hospital with She is admitted to hospital with the diagnosis “Query septic joint”the diagnosis “Query septic joint”
Joint aspirate cultures are Joint aspirate cultures are negativenegative
Is this an infection?Is this an infection?
Mrs. D Mrs. D (cont.)(cont.)
Mrs. D’s urine cultures grow Mrs. D’s urine cultures grow Pseudomonas aeruginosaPseudomonas aeruginosa
Right hip xrays report no Right hip xrays report no significant findingssignificant findings
Her UTI is treated and she is Her UTI is treated and she is dischargeddischarged
Mrs. D Mrs. D (cont.)(cont.)
3 months post op, Mrs. D again 3 months post op, Mrs. D again presents with hip pain, fever and presents with hip pain, fever and an elevated WBCan elevated WBC
R hip Xray reports areas of R hip Xray reports areas of lucidity and possible loosening lucidity and possible loosening of the prosthesisof the prosthesis
Is this an infection?Is this an infection?
Mrs. D Mrs. D (cont.)(cont.) Urine culture is negative, CXR Urine culture is negative, CXR
shows no acute changesshows no acute changes CT scan of her R hip reports a fluid CT scan of her R hip reports a fluid
collection in the subcuticular tissuecollection in the subcuticular tissue The collection is aspirated:The collection is aspirated:
– Straw-colored fluidStraw-colored fluid– Cultures = ‘no growth’Cultures = ‘no growth’
Is this an infection?Is this an infection?
Mrs. D Mrs. D (cont.)(cont.)
Joint aspirate grew Joint aspirate grew Coagulase Coagulase negative staphylococcusnegative staphylococcus
She is admitted for ‘I&D of R Hip’She is admitted for ‘I&D of R Hip’ Diagnosis: ‘Query Infected R Hip’Diagnosis: ‘Query Infected R Hip’
Is this an infection?Is this an infection?
Mrs. D Mrs. D (cont.)(cont.)
Surgical Procedure: Evacuation Surgical Procedure: Evacuation of seroma, debridement and of seroma, debridement and liner exchange R hipliner exchange R hip
Surgeon’s Operative report: Surgeon’s Operative report: Evacuation of Seroma, Evacuation of Seroma, devitalized tissue debrided, joint devitalized tissue debrided, joint irrigated and liner exchanged irrigated and liner exchanged (no pus seen)(no pus seen)
Mrs. D Mrs. D (cont.)(cont.)
2:4 intraoperative tissue 2:4 intraoperative tissue cultures grow cultures grow Coagulase Coagulase negative staphylococcusnegative staphylococcus
A PICC is inserted course of A PICC is inserted course of Vancomycin is startedVancomycin is started
Is this an infection?Is this an infection? If yes, then what depth?If yes, then what depth?
Mrs. D Mrs. D (cont.)(cont.)
What are some possible reasons What are some possible reasons that Mrs. D developed a surgical that Mrs. D developed a surgical site infection?site infection?
What is the probable source of What is the probable source of the infection?the infection?
Mrs. D Mrs. D (cont.)(cont.)
Possible outcomes:Possible outcomes:– Cure – no further problemsCure – no further problems– Premature loosening and early Premature loosening and early
revisionrevision– Excision arthroplasty with 2-Excision arthroplasty with 2-
stage revisionstage revision
SurveillanceSurveillance
Safer Healthcare Now! Western Node
"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 (CDC )".
Dr. Peter Riben, Infection Control SpecialistBC Provincial Infection Control Network
Process of SurveillanceProcess of Surveillance
Determine an ObjectiveDetermine an Objective Identify variations in the rate within a Identify variations in the rate within a
clinically relevant time frame clinically relevant time frame
Process of SurveillanceProcess of Surveillance
Define the EventDefine the Event NNIS - superficial, deep, organ space NNIS - superficial, deep, organ space
Process of SurveillanceProcess of Surveillance
Identify the data sources, who Identify the data sources, who collects the data, how frequently, collects the data, how frequently, triggers and timing triggers and timing
Process SurveillanceProcess Surveillance
Data collection form Data collection form Numerator Numerator DenominatorDenominator
Process of SurveillanceProcess of Surveillance
Analyze, interpret, disseminate the Analyze, interpret, disseminate the information information