SURGICAL SITE INFECTION SURVEILLANCE

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Scottish Surveillance of Healthcare Associated
Infection Programme

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

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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

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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

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Surveillance is

• Policing!
• A survey
• Research
• Audit

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HPSs 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

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Todays climate and demands!

• Public awareness!
• Quality is at the heart of everyones agenda
• Clinical Governance
• Clinical Standards
• Accountability Reviews
• Performance Assessment Framework

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HAI - Extent of the problem

• 100, 000 patients affected per year
• 5000 deaths per year

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The Cost of HAI
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AIM
Scottish Surveillance of Healthcare Associated
Infection Programme

• To promote accurate completion of surgical site
  infection surveillance forms

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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

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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)

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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

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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

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• HAI Cost (pp) Nat Burden(M)
• SWI 3246 62.37
• in-patient only
• Source Plowman et al. Socio-Economic Burden of
  HAI

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Background to SSI surveillance What is the
problem?

• 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?

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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

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Scottish SSI Surveillance Programme the way
forward

• 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

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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

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PATIENT PATHWAYS FOR SSI SURVEILLANCE TO POST OP
DAY 30



































In
-
patient end of Surveillance

End of Surveillance

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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.
Produce local guidance and make forms, posters
and flowcharts available in key areas
Hold training sessions for key personnel to
include SSI definitions and data management
Ensure key personnel are prepared and all systems
are in place to commence the surveillance
The SSHAIP team at HPS should be involved at
these stages
Pilot and launch the programme
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All forms are uniquely identified and originate
in theatre
Project officer administrates the surveillance
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
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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 detailscompleted by wound surveillance
nurse on the ward post op
Demographic detailscompleted by wound
surveillance nurse on the ward pre-op
Patients with identified wound problems are seen
at wound surveillance clinics, or at home by the
wound surveillance nurse for wound review
Patients have a 24 hour answer service telephone
number to call with wound problems. Primary care
staff also liaise with wound surveillance nurse
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
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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
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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
  199622457-67

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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

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AIM
Scottish Surveillance of Healthcare Associated
Infection Programme

• To promote accurate completion of surgical site
  infection surveillance forms

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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

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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.)

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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)

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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

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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 (gt38oC) 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

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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.

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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

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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

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Organ/Space SSI

• 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

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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

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Extra criteria for organ/ space infection

• 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

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Other definitions of wound infections

• 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

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Surgical site microbiology

• 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

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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 scoregt3
• Wound classified as contaminated or dirty
• Duration of operation

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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.

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Wound Classes

• Clean
• Clean contaminated
• Contaminated
• Dirty or infected

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Wound Classes

• A minimum wound class is only indicative and may
  vary according to certain pre operative and intra
  operative events.
• The final classification of wound contamination
  must be confirmed in consultation with the
  surgeon, or by checking the patients records.

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Wound Classes

• Clean wounds An uninfected operative wound in
  which no inflammation is encountered and the
  respiratory, alimentary, genital or uninfected
  urinary tracts are not entered. In addition clean
  wounds are primarily closed and if necessary
  drained with closed drainage. Operative
  incisional wounds that follow non-penetrating
  (blunt) trauma should be included in this
  category if they meet the criteria.

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Wound Classes

• Clean contaminated wounds Operative wounds in
  which the respiratory, alimentary, genital or
  urinary tracts are entered under controlled
  conditions and without unusual contamination.
  Specifically, operations involving the biliary
  tract, appendix, vagina and oropharynx are
  included in this category, provided no evidence
  of infection or major break in sterile technique
  is encountered.

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Wound Classes

• Contaminated wounds Open, fresh, accidental
  wounds. In addition, operations with major breaks
  in sterile technique (e.g. open cardiac massage)
  or gross spillage from the gastrointestinal tract
  and incisions in which acute, non-purulent
  inflammation is encountered are included in this
  category.

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Wound Classes

• Dirty or infected wounds Old traumatic wounds
  with retained devitalised tissue and those that
  involve existing clinical infection or perforated
  viscera. This definition suggests that the
  organisms causing postoperative infection were
  present in the field before the operation.

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ASA Classification

• 1. Normal healthy patient
• 2. Patient with mild systemic disease
• 3. Patient with severe systemic disease that is
  not incapacitating
• 4. Patient with an incapacitating systemic
  disease that is a constant threat to life
• 5. Moribund patient who is not expected to
  survive for 24 hours with or without operation

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In Summary

• What am I looking for?
• Has an SSI occurred, are there defined signs and
  symptoms of infection?
• The onset date (signs and symptoms of infection
  present should be completed on the form when
  first noticed)
• Complete the form
• With pre, peri and post operative details (see
  form completion instructions)

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Form completion general points

• Place a cross in the appropriate box
• Use a dark pen or biro
• Correct errors by completely filling the box
  where the incorrect response is
• Write clearly within the boxes when completing
  free text and do not write on the line of the
  boxes
• An empty box does not imply anything!

X
2
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Form completion general points

• DO NOT
• Use light pens
• Use a tick
• Leave gaps
• Staple or tape through/over the four black
  cornerstone boxes
• Write or draw on the black unique identifier box
  in the bottom corner of the forms
• Photocopy forms (you may for your own use however
  HPS require all originals)

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Form completion general points

• Complete the form
• On discharge
• On death
• On transfer
• On re-operation (at the same surgical site)
• At day 30 (if patient is still an in-patient or
  PDS in being carried out)
• Even if there is an implant complete the form at
  this time.
• In some instances forms will continue to be
  completed during the post discharge surveillance
  period. Procedures should be in place locally for
  managing this.
• Remember to ensure that the box for no infection
  present is completed when surveillance ends.

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Conclusion

• Standardised methodologies for SSI surveillance
  are essential to allow valid, reliable and
  comparable data. This includes the use of a
  common set of understood definitions.
• The local multi-disciplinary team play an
  essential role in the success of SSI
  surveillance.
• SSI rates are key quality indicators for surgery

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In Summary.

• Understanding the definitions of SSIs and their
  clinical appearances are essential
• Accurate completion of surveillance forms is key
• Visit our updated SSHAIP Website
  www.show.scot.nhs.uk/scieh/  - select HAI
  Infection Control.