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All About Surgical Site Infections

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Title: All About Surgical Site Infections


1
All About Surgical Site Infections
  • Lessons learned from the SSI surveillance pilot,
    SSI mini grant program, and the data presentation
    collaborative

Andrea Alvarez, MPH HAI Program
Coordinator Virginia Department of
Health Jacqueline P. Butler, CIC Dir, Infection
Prevention Control Sentara Healthcare November
10, 2011
2
SSI Surveillance Pilot Purpose
  • Public reporting expectations increasing
  • Multiple factors to consider when choosing a SSI
    for public reporting
  • Troubleshoot issues with surveillance definitions
  • Quantify time requirements for surveillance
  • Gather lessons to help prepare other facilities
    for reporting

3
Perceived Pilot Benefits
  • Increase awareness of SSIs
  • More focus on prevention practices, monitoring
    associated outcomes, physician awareness of
    surveillance definitions
  • High profile, high risk, high priority procedures
  • Providing standardized benchmark data
  • Prepare for future reporting requirements
  • Gain more experience in NHSN data entry
  • Increase upload or electronic capabilities
  • Quantify the time associated with procedure
    surveillance
  • Identify demands for reporting to facilitate
    processes to reduce burden
  • Feed data back to those who can make a difference

4
SSI Pilot Methods Selecting Hospitals and
Procedures
  • Coronary artery bypass graft (CABG), hip
    replacement (HPRO), knee replacement (KPRO)
    surgeries
  • Consumer interest, experiences of other states,
    morbidity
  • Surgical Care Improvement Project (SCIP)
    antibiotic measures
  • Align process measures with outcome measures
  • Pilot feasibility of publicly reporting
    procedure-specific SCIP data
  • 18 hospitals
  • Randomly selected by bedsize category and number
    of procedures performed
  • Voluntary participation
  • Incentives educational stipend (conferences,
    journal subscriptions, etc.)

5
Pre-Survey
  • 18/18 facilities responded (100)
  • Well prepared
  • 100 enrolled in NHSN and used NHSN definitions
  • 94 calculated SSI rates
  • Relatively well prepared
  • 2/3 currently collected patient-level information
  • Prevention efforts already underway
  • SSI surveillance deemed high or medium priority
  • Not well prepared
  • One facility was currently entering data into
    NHSN for the pilot procedure
  • No facilities currently uploaded denominator data
  • Limited communication between surgical and IP
    databases
  • 50 perceived surveillance to be somewhat or very
    difficult

6
Methods - Training
  • Partnership with APIC-VA for training and
    distribution of incentives
  • One-day training (June 9, 2010)
  • Case studies prepared by APIC-VA
  • Monthly conference calls
  • Surveillance QA
  • Data import discussions
  • Feedback of data

7
Some Surveillance Pointers
  • Definitions Ensure the latest version of the
    definitions are being used
  • Deep incisional vs. organ space
  • Increases consistency and standardization
  • SSIs are attributed to the date of the operation
  • For SSIs identified on readmission, on the event
    form use the date of admission and discharge for
    the surgery visit
  • All surgical procedures must be entered into NHSN
  • Not only procedures with an event (like CLABSIs)
  • Only need to report the required sensitivities
  • To report a pathogen that is not on the list of
    common pathogens, right-click in pathogen field

8
NHSN Clarifications
  • Deep incisional vs. organ space
  • If an incision is opened, the infection is
    counted as deep incisional no matter where it
    travels
  • A knee that has never been operated on before is
    always a primary regardless of whether it is a
    total or partial surgery
  • Transplant
  • Includes internal staples
  • Does not include a blood transfusion
  • SSI standardized infection ratios (SIRs) only
    include primary sites

9
Methods Data Reporting
  • Monthly entry of procedures and infection events
    into NHSN
  • Procedures from July Dec 2010 with 6 months of
    post-discharge surveillance
  • Quarterly submission of SCIP data
  • Jan-June 2010 (baseline), July-Dec 2010 (pilot)
  • Time and effort
  • Time spent on surveillance
  • Number of staff involved with surveillance

10
Electronic Upload Methods ASCII File
  • Comma delimited ASCII file (.txt or .csv) created
    by the facility
  • Can be generated from different external sources,
    such as infection prevention databases or
    hospital information systems
  • Requires assistance of operating room and/or IT
    staff
  • Specifications for values, format, and data
    requirements must be followed
  • Specifications and instructions available on NHSN
    website
  • http//www.cdc.gov/nhsn/PDFs/ImportingProcedureDat
    a_current.pdf

11
Electronic Upload Methods CDA
  • Clinical Document Architecture (CDA)
  • Health Level 7 (HL7) standards used to provide a
    consistent format framework for electronic
    documents
  • Not all vendors have the capacity to create
    documents in this HL7 framework
  • Specifications and instructions available on NHSN
    website
  • http//www.cdc.gov/nhsn/ CDA_eSurveillance.html
  • Examples of vendors with CDA compatibility
  • Atlas Development Corporation
  • BD Diagnostics (formerly known as AICE or ICPA)
  • CareFusion / MedMined from Cardinal Health
  • Cerner Corporation
  • EpiQuest
  • ICNet International Limited
  • RL Solutions
  • SafetySurveillor by Premier
  • Sentri7 by PharmacyOne
  • TheraDoc Hospira, Inc.

List compiled by APIC
12
SSI Pilot Time and Effort per Facility
2010
2011
Readmission/post-discharge only
13
SSI Pilot Time and Effort per Person
2010
2011
Readmission/post-discharge only
14
Results SCIP Data
  • SCIP 1 Timely receipt of antibiotic prior to
    surgery
  • SCIP 2 Receipt of appropriate antibiotic
  • SCIP 3 Timely discontinuation of antibiotic
    after surgery

15
Results SSIs Identified
  • 2,388 procedures conducted
  • 25 SSIs included in SIR calculation
  • Secondary infections are not included in SIR
  • - All CABG (N5)
  • 64 CABG, 24 KPRO, 12 HPRO
  • ASA score and duration of procedure highest for
    CABG
  • 3 occurred gt 30 days after procedure (all KPRO)
  • SIR 0.72
  • Interpretation The pilot facilities identified
    28 fewer SSIs than expected based on the
    national experience.
  • Not statistically significant

16
Post-Survey
  • 14/18 facilities responded (78)
  • Facilities more prepared for public reporting
  • Staff review SSI definitions more closely
  • IT changes
  • Many facilities changing or considering changing
    vendors
  • Changes to administrations prioritization of
    SSI surveillance (4 facilities)
  • No change in IPs perspective of the magnitude of
    the problem of SSIs in their facility

17
Benefits to Participation
  • 93 - Helped to prepare for future reporting
    requirements
  • 79 - Gained more experience in NHSN data entry
  • 57 - Facilitated process needed to meet pilot
    demands and future reporting
  • 50 - Demonstrated how much time was associated
    with HAI surveillance to find ways to decrease
    burden on workload
  • 43 - Automated upload and/or increased
    electronic capabilities
  • 43 - Increased awareness of SSIs

18
Barriers Encountered
  • 50 Learning curve
  • Data entry
  • Importing data
  • 43 Time/resource limitations
  • Data entry
  • Staffing
  • 29 No barriers
  • 14 Post-discharge surveillance
  • 14 Consistency between facilities

19
Electronic Upload to NHSN
  • Pre-survey 0 facilities End of pilot 9
    facilities (50!)
  • 6 facilities submitted feedback on upload process
  • 4 used Clinical Document Architecture (CDA)
    technology
  • 3 BD/AICE, 1 unspecified vendor
  • Decreases in monthly surveillance effort after
    implementing CDA
  • 8 hours to 2 hours
  • 8 hours to 1 hour
  • Time required to set up import averaged several
    months
  • 2 used .CSV file
  • Decreased monthly surveillance effort in one
    hospital from 5 hours to 1 hour
  • Took 2 months for one hospital to set up its file
    transmission
  • 2 hospitals used DICON to help with their
    electronic import
  • 4 of these hospitals used Meditech for their
    patient medical records

20
Lessons Learned / Challenges
  • Electronic medical record system (EMR) is
    necessary for the electronic upload and any
    movement towards increased use of EMR would be of
    help to the facility
  • Helpful to talk to other facilities using the
    same systems and see if they have been able to
    set up a file transfer
  • Sometimes easier for facility IT staff to talk to
    each other rather than IP trying to explain to IT
    what is needed
  • Importance of monitoring all exported data for
    quality

21
Lessons Learned / Challenges
  • Operating room system capability and
    compatibility
  • Writing the data dictionaries challenge!
  • Concern about changing dictionaries/remapping
    elements if NHSN amends definitions or changes
    required fields
  • Team approach required (quality, IT, other
    departments)
  • Establish importance of support of the infection
    prevention program on a local level first
  • IT support is critical for implementation and to
    address data quality
  • Vendor representatives can play a beneficial role

22
PERSPECTIVES FROM THE PARTICIPANTS
23
Experiences of a Large System
  • Sentara Healthcare (SH)
  • gt23,000 staff, gt100 care giving sites,
    including 10 acute care hospitals with a total
    of 2,349 beds
  • Sentara Norfolk General Hospital / Sentara Heart
    Hospital
  • Patients receive comprehensive cardiac services -
    from diagnostics to open heart surgery and
    transplants.
  • State-of-the-art hospital features all-private
    rooms, including 112 inpatient beds and 45
    pre/post procedural rooms for patients undergoing
    interventional cardiac procedures.
  • Houses 5 cardiac operating rooms designed to
    accommodate 2,000 cardiac surgeries a year.

24
Timeline of Sentaras Pilot Period
  • Calm down
  • Education June 9, 2010
  • Define current surveillance process for CABG
  • Develop a Team (IT, Contracted Vendor, Cardiac
    Auditors, Leadership, IPC) to research ability
    to electronically export denominator surgical
    data to NHSN
  • Contracted Cardiac Vendor building a background
    program to develop a report off the STS Cardiac
    Surgery Database (CSD) for exporting
  • Began reporting requirements for pilot project
    (numerator data, denominator data export, SCIP
    measure data, time effort measures) September
    1, 2010 for July 2010 data
  • Completion ongoingWhy stop a good process?

25
Sentaras Experiences
  • Pit Falls
  • Took time to map SH surgical denominator
    components (STS CSD) to NHSN template for export
  • Time allotment for cardiac abstractors to review
    surgical patients
  • Contracted vendor - Armus
  • Experience
  • Positive
  • Demonstrated SHs ability to address issues of
    mandatory reporting

26
Building in a Collaborative
  • Requirement of ARRA funding
  • Create a project to be flexible and responsive to
    acute care IPs workload
  • Collecting data presentation templates
  • Sharing best practices for data feedback
  • Monthly conference calls
  • Survey given to IPs and unit-specific staff to
    capture the various perceptions of data utility

27
Data Presentation Survey
  • Collect baseline of knowledge regarding data
    presentation practices targeted to direct care
    staff
  • Sent to IPs, direct care staff in a selected
    unit/area
  • 18 facilities (100) 17 IPs and 84 staff
  • General statements about use of data to lower HAI
    rates or impact infection prevention compliance
  • Types of staff and their perceived awareness of
    HAI data and compliance with infection prevention
    practices
  • Outcome and process measures staff want to see
    and are currently provided
  • Types of data and whether they are easy to
    understand, useful, and currently presented

28
Data Presentation Survey Results IP and Staff
Perceptions
  • Awareness of HAI data promotes dialogue among
    staff and impacts infection prevention compliance
  • IPs more likely to think that SSI rates were
    improving (65 vs. 48)
  • Most respondents thought unit-specific HAI data
    were valid and reliable, easy to understand,
    timely, and shared at least quarterly

29
Survey Results (contd)
  • Color coding, comparisons (to average, benchmark)
    most useful to staff
  • Color coding, comparisons, HAI rates, number of
    HAIs, and number of days since last infection
    were most easy to understand
  • SIR used in some hospitals (20), useful (38),
    easy to understand (26)
  • HAI data most often presented HH, CLABSI
  • Staff want environmental cleaning compliance
    data however, it is least likely provided to
    unit

30
Survey Results (contd)
  • Differences in awareness of what data are
    presented (IPs vs. staff receiving data)
  • Perceived differences in awareness of data and
    infection prevention compliance by type of staff
  • Most aware and compliant nursing leadership,
    unit nurses
  • Least aware and compliant physicians
  • IPs share data most often with units and
    Infection Control Committee
  • gt75 of respondents present HH, BSIs, SSIs, UTIs,
    VAPs
  • gt75 of respondents present comparison HAI data

31
SSI Pilot SIR by Time Period
More infections than predicted
(statistically significant) Observed
number of infections similar to predicted
Fewer infections than predicted (statistically
significant) No infections ---SIR 1.00
when observed predicted
32
SSI Mini-Grant Program
  • Any activities that support implementation of the
    NHSN Procedure-Associated Module, including but
    not limited to
  • Equipment and services, such as administrative
    and informatics costs
  • Example upgrading or modifying internal systems
  • Training and education
  • Example training for staff responsible for
    collecting and/or entering surgical site
    infection surveillance data
  • Consultative and technical assistance
  • Example programmer support to help create an
    electronic file to upload surgical procedure data
    directly into NHSN
  • Administrative support

33
Awardees
  • Applications reviewed by VDH and Virginia
    Hospital Healthcare Association (VHHA)
  • 22 hospitals
  • Total of 290,000
  • Monies dispersed by July 2011

34
PERSPECTIVES FROM THE PARTICIPANTS
35
Sentara A Systems Approach
  • Total funding 145,000 for System
  • Technical assistance (IT) 124,000
  • Training Infection Prevention Control (IPC),
    Data Auditors - 21,000
  • Implementation goals
  • Develop and implement an electronic export
    process for reporting of surgical procedure data
    directly into the NHSN database
  • Provide training / technical assistance to staff
    to facilitate successful implementation of the
    exporting process
  • Create super users / trainers who will
    disseminate the process throughout the Sentara
    Healthcare System

36
Sentara A Systems Approach
  • Time Line
  • Awarded mini-grants - May 2011
  • Immediately developed Team (IT, Leadership,
    Finance, IPC) to address goals of funding
  • IT Team began meeting with an action plan based
    on components (IT, Training) - June 2011
  • Hired Consultant to develop IT components from
    PICIS OR Manager and background data fields -
    July 2011
  • Pit Falls
  • Other IT priorities (EPIC Go Live)
  • Contracted IT staff
  • Time line finances
  • Experience
  • Frustration

37
Next Steps for Sentara
  • Activity reports (facility-specific) and unused
    funding submitted to VDH/VHHA
  • November 15, 2011
  • Implementation of final IT product
  • November 2011
  • Trial use of IT product by IPC
  • December 2011
  • Validation of process by IPC
  • December 2011 - January 2012
  • Use of product beginning with Jan 2012 surgical
    patient population with successful export of data
    to NHSN
  • February 2012

38
Lessons Learned Other Facilities
  • Electronic medical records are great but present
    documentation challenges
  • Surgeons do not use ICD-9 codes
  • Mapping of required denominator components time
    consuming
  • IT needs special handling

39
Resources/Take Home Messages
  • Challenge of converting CPT codes to ICD-9 codes
  • Crosswalk soon available!
  • NHSN forms for Procedure-Associated Module
  • http//www.cdc.gov/nhsn/psc_pa.html
  • Map entire facility in NHSN infections can
    happen anywhere
  • Resources to Help Build Business Case for
    Electronic Upload (VDH document)
  • Future training opportunities APIC-VA and NHSN

40
Acknowledgments
  • VDH Dana Burshell, Carol Jamerson, Diane
    Woolard
  • VHHA Barbara Brown
  • APIC-VA
  • SSI pilot participants
  • SSI mini-grant recipients

41
The Purpose of Our WorkThe names of the
patients whose lives we save can never be known.
Our contribution will be what did not happen to
themDonald M. Berwick, MD, MPPFormer
President and CEO of IHICurrent Administrator of
CMS
Andrea.Alvarez_at_vdh.virginia.gov
804-864-8097 JPButler_at_sentara.com
757-388-3949
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