SURGICAL SITE INFECTIONS

SURVEILLANCE & PREVENTION

Objectives

• List evidence based prevention strategies

• Define Surgical Site Infections based on

NHSN definitions

• Describe surveillance tips

Facts

According to 2018 Patient Safety Movement Foundation:

• There are approximately 300,000 SSIs annually.

• 17% of all HAIs, second only to UTIs.

• SSIs occur in 2%-5% of patients undergoing inpatient surgery

• The SSI mortality rate is 3% with a 2-11% times higher risk of death versus other infections.

• 75% of deaths among patients with SSI are directly attributable to the SSI.

• Long term disabilities can result from SSIs, resulting in life-altering disabilities and associated financial burdens.

So what’s reportable in Texas?

Prevention of SSI

• Pre-operative Skin cleansing with CHG and educate patients on how to apply/bathe/shower & shampoo prior to surgery

• Pre-operative screening for patients at risk for SSI.

• Nasal screening for Staphylococcus aureus in patients undergoing cardiac and elective orthopedic surgery

• Decolonize protocol for carriers with intranasal meds.

• Educate patients & families on SSI prevention.

• Stop smoking – affects wound healing

• Proper nutrition

• Diabetes needs to be controlled

• Identify skin irritations and hypersensitivity & any new skin abrasions

• Post-op wound healing techniques used

• Proper Hand Hygiene

• Proper hair removal (NO SHAVING or RAZORS, clipping only those areas needed).

• Appropriate timing, selection and duration of prophylactic antibiotics

• Maintain normothermia with forced air blankets, pre-op, during surgery and in PACU.

• Use warmed IV fluids for IVs and flushes

• Traffic control in the OR

• Protect primary closure incisions with sterile dressing for 24-48 hours post-op

• Discontinue ABX within 24 hours after surgery unless s/s of infection are present.

• that is included in the ICD-10-PCS or CPT NHSN operative procedure code mapping

AND

• takes place during an operation where at least one incision (including laparoscopic approach and cranial Burr holes) is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure

AND

• takes place in an operating room (OR), defined as a patient care area that met the Facilities Guidelines Institute’s (FGI) or American Institute of Architects’ (AIA) criteria for an operating room when it was constructed or renovated11. This may include an operating room, C-section room, interventional radiology room, or a cardiac catheterization lab.

NHSN Operative Procedure

NHSN Inpatient Operative Procedure

NHSN Inpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and the date of discharge are different calendar days.

NHSN Outpatient Operative Procedure

NHSN Outpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and date of discharge are the same calendar day.

Primary Closure

Primary Closure = closure of the skin level during the original surgery, regardless of the presence of wires, wicks, drains, or other devices or objects extruding through the incision, includes surgeries where the skin is closed by some means. Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery.

NOTE: If a procedure has multiple incision/laparoscopic trocar sites and any of the incisions are closed primarily, then the procedure is entered as having been closed primarily.

• This change removed the phrase “all tissue levels” from the definition. This definition will be easier to apply and is closer to definitions used by other surgical professional groups.

Non- Primary Closure• Skin level is left completely open during the original surgery

• Deep tissue layers may be closed by some means (with the skin level left open), or the deep and superficial layers may both be left completely open.

• Wounds with non-primary closure may or may not be described as "packed” with gauze or other material, and may or may not be covered with plastic, “wound vacs,” or other synthetic devices or materials.

• For example: a laparotomy in which the incision was closed to the level of the deep tissue layers, sometimes called “fascial layers” or “deep fascia,” but the skin level was left open.

• For example: an “open abdomen” case in which the abdomen is left completely open after the surgery.

Case 1

• A patient is admitted with a ruptured diverticulum and a COLO procedure is performed in the inpatient OR.

• Case is entered as a wound class 3

• Specimen is obtained in the OR which later returns (+) for E. coli

• The skin incision was closed at 4 locations with staples with gauze packing in between.

Is this procedure primarily closed?

1. Yes

2. No

Is this procedure primarily closed?

1. Yes

2. No

Case 1 -Rationale

The skin is closed at some points along the skin incision.

Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery.

If you are following COLO in your monthly reporting plan should this case be entered into your denominator data?

1.Yes

2.No

If you are following COLO in your monthly reporting plan should this case be entered into your denominator data?

1.Yes

2.No

Surveillance

• Surveillance of SSIs with feedback of appropriate data to surgeons has been shown to be an important component of strategies to reduce SSI risk.

• A successful surveillance program includes the use of epidemiologically sound infection definitions and effective surveillance methods– stratification of SSI rates according to risk factors associated with SSI

development

– data feedback

A new CDC and Healthcare Infection Control Practices Advisory Committee guideline for the Prevention of Surgical Site Infection has been published in 2017 and has replaced the previous Guideline for Prevention of Surgical Site

Infection, 1999

CDC Definitions

• NHSN manual from Jan 2018– http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.

pdf

• 3 Types– Superficial Incisional SSI

– Deep Incisional SSI

– Organ/ Organ Space

Sources of Data for Finding SSI

• Microbiology reports

• Infection control rounds on nursing units

• Pharmacy reports for antimicrobial use

• Operating room report of surgeries

• Use post-discharge surveillance methods for SSI

• Electronic Surveillance Programs

• ER Diagnosis List

• Case Managers

• IPs in your community!

Important Information!

• Please note that key terms that have been defined in other NHSN trainings (e.g. CLABSI, CAUTI) including Infection Window Period, Present on Admission (POA), Healthcare-associated Infection (HAI), and Repeat Infection Timeframe (RIT) DO NOT apply to SSI!

Date of Event

• Date of event (DOE): For an SSI the date of event is the date when the first element used to meet the SSI infection criterion occurs for the first time during the surveillance period.

• The date of event must fall within the SSI surveillance period to meet SSI criteria.

DOE for SSIs that progress to a deeper level during surveillance period

SSIs are always reported at the deepest level that they occur within the surveillance period.

If during the surveillance period a patient’s initial SSI meets criteria for a deeper level, then the date of event should be the date for the deepest level.

Example

For example:

• Day 1 –COLO procedure

• Day 6 –DOE for meeting a superficial incisional SSI

• Day 25 –DOE for the meeting an organ space IAB SSI

• Only report one SSI with the DOE for the organ space IAB

Pathogen Assignment

• The Pathogen Assignment Guidance found in Chapter 2 “Identifying HAIs” is based on Repeat Infection Timeframes (RIT) which is not used with SSIs

• SSI are procedure based and have long surveillance periods (30 to 90 days)

• SSIs can progress to a deeper level during a surveillance period and a new pathogen can be found.

• Pathogen Assignment for SSI has not changed.

BSI Secondary to an SSI

Secondary BSI Attribution Period: The secondary BSI attribution period for SSI is a 17-day period that includes the date of SSI event, 3 days prior & 13 days after.

For other HAIs the Secondary BSI attribution period is determined by using:

➢ Infection Window Period

➢ Repeat Infection Timeframe.

These two definitions do not apply to SSI.

• Any blood culture that occurs during the SSI Secondary BSI attribution period will be assessed using Appendix B in the BSI protocol to determine if the blood meets Secondary BSI criteria.

• If a (+) blood culture occurs after the SSI secondary BSI attribution period it should be fully evaluated to see if at that time it is meeting criteria to be secondary to an ongoing SSI.

PATOS- Infection present at time of surgery

• Infection present at time of surgery (PATOS) denotes there is evidence of an infection/abscess at the time of the start of or during the index surgical procedure (present pre-operatively).

• This field is a required field and it is found on the SSI event form not on the denominator for procedure form.

• Only select PATOS = YES if it applies to the depth of SSI that is being attributed to the procedure

• IF:

➢ a patient had evidence of an intra-abdominal infection at the time of surgery and then later returns with an organ space SSI the PATOS field would be selected as a YES.

➢ If the patient returned with a superficial or deep incisional SSI the PATOS field would be selected as a NO.

The patient does not have to meet the NHSN definition of an SSI at the time of the primary procedure but there must be notation that there is evidence of infection or abscess present at the time of surgery.

• All of the SSI SIR reports that use the new 2015 SSI baseline will exclude SSIs that are reported as present at time of surgery from both the numerator and denominator.

–Meaning the PATOS event is excluded in the numerator of the SIR and the procedure from which the event occurred is excluded in the denominator of the SIR.

Case 2

• Patient was admitted with an acute abdomen, to OR for XLAP with findings of an abscess due to ruptured appendix and an APPY is performed.

• Patient returns 2 weeks later and meets criteria for an organ space IAB SSI.

Does this patient meet the criteria for PATOS?

1. PATOS= NO

2. PATOS= YES

Does this patient meet the criteria for PATOS?

1. PATOS= NO

2. PATOS= YES

Since this SSI is related to an infection that was PATOS it does not have to be reported to NHSN.

1. True

2. False

Since this SSI is related to an infection that was PATOS it does not have to be reported to NHSN.

1. True

2. False

Case 2 -Rationale

• The PATOS field would be selected as YES since there was evidence of infection at the time of surgery and the subsequent SSI developed at the same level.

• Infections that meet SSI criteria and have the PATOS field as a YES are reported to NHSN.

Reporting Instruction -24 Hour Rule (SSI Protocol 9-20)If the wound class has changed, report the higher wound class. If the ASA class has changed, report the higher ASA class. Note: When the patient returns to the OR within 24 hours of the end of the first procedure assign the surgical wound closure technique that applies when the patient leaves the OR from the first operative procedure.

Same NHSN operative procedure via separate incisions

For operative procedures performed via separate incisions during same trip to operating room (i.e., AMP, BRST, CEA, FUSN, FX, HER, HPRO, KPRO, LAM, NEPH, OVRY, PVBY, REFUSN), separate Denominator Procedure forms are completed.

To document the duration of the procedures, indicate the procedure/surgery start time to procedure/surgery finish time for each procedure separately

OR

alternatively, take the total time for the procedures and split it evenly between procedures.

SSI Chapter : Denominator Data Reporting Instructions

Case 3

A patient had bilateral knee prostheses (KPRO) implanted during a single trip to the OR.

–Left KPRO PST at 8:30 am there was no note of a finish time for this knee

–Right KPRO PF time was at 11:30 am

Which Statement is correct?

1. One KPRO procedure should be reported with a combined duration of 3hrs 0 min

2. Two Separate KPRO procedures should be reported, each with a duration of 1hr 30 min

3. Two separate KPRO should be entered, each with a duration of 3hrs 0 min

Which Statement is correct?

1. One KPRO procedure should be reported with a combined duration of 3hrs 0 min

2. Two Separate KPRO procedures should be reported, each with a duration of 1hr 30 min

3. Two separate KPRO should be entered, each with a duration of 3hrs 0 min

Procedures that can never be coded as clean wound class

The procedures that can never be entered as clean are: APPY, BILI, CHOL, COLO, REC, SB and VHYS. In the application, clean is not on the drop down menu.

A CSEC, HYST, or OVRY can be a clean wound class based on the particular events and findings of an individual case.

Wound class should be set by someone who is part of the surgical team based on the findings of each specific case.

Diabetes

• NHSN has added another option for users to answer the question of diabetes on the denominator for procedure form.

• The ICD-10-CM diagnosis codes that reflect the diagnosis of diabetes are also acceptable for use to answer YES to the diabetes field question on the denominator for procedure entry if they are documented during the admission where the procedure is performed

• Definition includes those with diagnosis of diabetes requiring management with insulin or a non-insulin anti-diabetic agent.

• Definition excludes people who receive insulin for perioperative glucose control but have no diagnosis of diabetes.

Reporting Instruction : Labor

• Length of time from beginning of active labor as an inpatient to delivery of the infant, expressed in hours

• No labor, hours = 0

• Check for documentation in the chart

• May be defined by your hospital’s policies and procedures but should reflect the onset of regular contractions or induction that leads to delivery during this admission

HPRO and KPRO Revisions

• If performed, evaluate whether any diagnoses indicating possible infection (acquired absence of hip or knee joint, with or without the presence of an antibiotic-impregnated spacer) or any procedures such as insertion or replacement of cement spacer or removal of cement spacer were coded in the 90 days prior to and including the index HPRO or KPRO revision.

• This field will only open on the application if the case has been entered as a HPRO or KPRO revision.

CDC Definitions• Superficial (Primary or Secondary)

– Infection occurs within 30 days after NHSN operative procedureAnd– Infection involves only skin or subcutaneous tissue of the incision And patient has at least one of the following:

a) Purulent drainage from superficial incisionb) Organisms identified from an aseptically-obtained specimen

from the superficial incision or subcutaneous tissue by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST)

c) Superficial incision that is deliberately opened by a surgeon, attending physician or other designee and culture or non-culture based testing is not performed

AND Patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; erythema; or heat.

d) Diagnosis of a superficial incisional SSI by the surgeon orattending physician or other designee

Superficial Incisional SSI Reporting

• Diagnosis/treatment of cellulitis (redness/warmth/swelling), by itself, does not meet criterion “d” for superficial incisional SSI. Conversely, an incision that is draining or that has organisms identified by culture or non-culture based testing is not considered a cellulitis.

• A stitch abscess alone (minimal inflammation and discharge confined to the points of suture penetration) is not considered an SSI.

• A localized stab wound or pin site infection. While it would be considered either a skin (SKIN) or soft tissue (ST) infection, depending on its depth, it is not reportable under this module.

Note: a laparoscopic trocar site for an NHSN operative procedure is not considered a stab

wound.

Case 4

• 2/15 -62 year-old female admitted and underwent a total knee arthroplasty (KPRO)

• 2/17 -Patient discharged

• 3/9 -Patient is seen in the physician office after the patient tripped and fell at home. There is drainage noted from the superficial incision. A culture is collected from the drainage. The culture grows coagulase-negative staphylococci (CoNS).

What would be reported?

1. SSI –SIP attributable to the KPRO

2. SSI –DIP attributable to the KPRO

3. Nothing. The wound culture grew common skin flora only.

4. Nothing. The patient fell at home, therefore you cannot attribute an SSI to the KPRO procedure.

Rationale

• Common commensals are not excluded from SSI determination.

• Culture results of “mixed flora” or “mixed cutaneous flora” cannot be reported to NHSN as there is no such pathogen option in this list of pathogens.

Numerator Reporting Instruction #12:

• An SSI that otherwise meets the NHSN definitions should be reported to NHSN without regard to post-operative accidents, falls, inappropriate showering or bathing practices, or other occurrences that may or may not be attributable to patients’ intentional or unintentional postoperative actions.

Table 4NHSN Principal Operative Procedure Category Selection Lists

Deep Incisional SSI

An Infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according to the procedure list

AND

Involves deep soft tissues of the incision (e.g. fascial and muscle layers)

AND

Patient has at least one of the following:

a. Purulent drainage from the deep incision.

b. a deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician** or other designee and organism is identified by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST) or culture or non-culture based microbiologic testing method is not performed

AND patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or tenderness. A culture or non-culture based test that has a negative finding does not meet this criterion.

c. an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam, or imaging test

Case 5

• 11/1 -Patient is admitted to the hospital for an HPRO –revision. No evidence of infection at the time of the surgery.

• 11/4 -Postoperative course is unremarkable; patient discharged.

• 11/18-Patient is readmitted with complaints of pain and swelling since 11/16. To OR for left hip I&D. Serous fluid was cultured from the fascial layer.

• 11/19 -Culture result returned and is positive for Staph epidermidis in broth only.

Is this an SSI?

1. Yes, meets criteria

2. No, colonized with MRSA so this was POA

What infection should be reported?

1. SSI-SIP

2. SSI-SIS

3. SSI-DIP

4. SSI-DIS

5. SSI-IAB

Organ/Space SSI Infection

Infection occurs within 30 or 90 days after the NHSN operative procedure

(where day 1= procedure date) according to the procedure list

AND

Infection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure

AND

Patient has at least one of the following:

– Purulent drainage from a drain that is placed into the organ/space (e.g. closed suction drainage system, open drain, T-tube, CT

Guided drainage).

– Organisms isolated from an aseptically-obtained fluid or tissue in the organ/space by a culture or non-culture based microbiologic testing method (not ASC/AST).

– An abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test evidence suggestive of infection

AND

Meets at least one criterion for a specific organ/space infection site listed.

These criteria are in the Surveillance Definitions for Specific Types of Infections Chapter.

2 different criteria must be met for Organ/Space SSI• SSI organ/space criteria

• AND• Those of the specific site of the organ/space

operated on

SSI event form Table of Instructions

Organ Space SSI

Table 3Specific Sites of an Organ/Space SSI.

Reporting Instruction

Attributing SSI to an NHSN procedure when there is evidence of infection at the time of the primary surgery:

POA definition does not apply to the SSI protocol.

If there was evidence of infection at the time of the procedure and then later in the surveillance period the patient develops an infection that meets the NHSN SSI criteria, it is attributed to the procedure.

A high level wound class is not an exclusion for a patient later meeting criteria for an SSI.

Case 6

• On 2/1 -Patient presents to ED with acute abdomen and is admitted to the OR on the same day for colon resection (COLO). Peritoneal abscess noted at time of surgery. Abdominal abscesses drained and thorough abdominal washout, incision loosely closed with some packing between staples and a JP drain is placed in an adjacent stab wound.

• 2/4 -Patient discharged, wounds healing well.

• 2/8 -Patient presents to ED with fever, abdominal pain, and sent to CT for CT guided drainage of an abscess.

• This is reported as an SSI-IAB (meets IAB criterion b and 3a.)

• The PATOS field would be entered as a YES

Case 6

• If during the post-operative period the surgical site has an invasive manipulation/accession for diagnostic or therapeutic purposes (e.g., needle aspiration, accession of ventricular shunts, accession of breast expanders ) and there is no evidence of an infection at that time, if an SSI develops following this manipulation/accession, the infection is not attributed to the operation.

• This reporting instruction does NOT apply to closed manipulation (e.g., closed reduction of a dislocated hip after an orthopedic procedure).

• Invasive manipulation does not include wound packing, changing of wound packing materials or staple removal as part of postoperative care.

Different operative procedure categories performed via same incision during same trip to the OR:

First, attempt to determine the procedure that is thought to be

associated with the infection.

Example: If the patient had a CBGC and CARD-AVR done at the same

time and returns and meets criteria with an infected valve, then the

SSI will be linked to the CARD-AVR.

If it’s not clear (as in the case of a superficial incisional SSI), use the

NHSN Principal Operative Procedure Selection Lists to select which

operative procedure to report.

Categories with the highest risk of SSI are listed before those with lower risks

Case 7

• 10/8 -Patient admitted and underwent laparoscopic hysterectomy (HYST). Wound class 2.

• 10/15 -Readmitted with abdominal pain. CT showed fluid and air in pelvis. To OR for COLO where purulence was noted in the deep pelvic area.

Does this patient meet criteria for an organ space SSI?

1. Yes2. No

What site specific SSI does this patient have?

• SSI-DIP

• SSI-IAB

• SSI-OREP

• Not an SSI

OREP-Deep pelvic tissue infection or other infection of the male or female reproductive tract (epididymis, testes, prostate, vagina, ovaries, uterus, chorioamnionitis, excluding vaginitis, endometritis or vaginal cuff infections)

OREP Criterion 2:Patient has an abscess or other evidence of infection of affected site on gross anatomic or histopathologic exam.

Why isn’t this an SSI-IAB?

IAB –Intraabdominal, not specified elsewhere including gallbladder, bile ducts, liver (excluding viral hepatitis), spleen, pancreas, peritoneum, subphrenicor subdiaphragmaticspace, or other intraabdominal tissue or area not specified elsewhere

Site Définitions Chapter; Chapter 17

Case 8

• 3/9 –49 year-old patient goes to OR for a XLAP and COLO procedure.

• 3/17 –Patient complains of new abdominal pain.

• 3/18 –Temperature noted of 100.5. CT of abdomen findings: severe colon thickening -correlate with enteritis/colitis. Blood cultures obtained. Physician initiates and documents antimicrobial treatment for gastrointestinal tract infection.

• 3/20 –Blood cultures return positive P. aeruginosa.

Does this patient meet criteria for an SSI?

1. Does not meet SSI criteria

2. SSI Organ/Space, specific site GIT, with a secondary BSI

3. SSI Organ/Space, specific site IAB, with a secondary BSI

4. SSI Organ/Space, specific site GIT without secondary BSI

Rationale Case 8-GIT Criterion 2d Patient has at least two of the following signs or symptoms compatible with infection of the organ or tissue involved: fever (>38.0°C), nausea*, vomiting*, pain*or tenderness*, odynophagia*, or dysphagia*

And at least one of the following:d. imaging test evidence suggestive of infection (e.g., endoscopic exam, MRI, CT scan), which if equivocal is supported by clinical correlation (i.e., physician documentation of antimicrobial treatment for gastrointestinal tract infection).

*With no other recognized causeP. aeruginosa is not an MBI organism –must investigate blood cx

as secondary to another source or as primary LCBI

Case 8 -Rationale

Why not IAB –Intraabdominal infection as the specific site of SSI?• The infection is in the gastrointestinal tract and not

involving the intraabdominal space• GIT focuses on infections of the gastrointestinal

tract• Therefore, GIT is the appropriate choice site of SSI in

this case

Site Definitions Chapter; Chapter 17

Questions?