SURGICAL SITE
INFECTION
SURVEILLANCE
STANLEY OSTRAWSKI, MS, RN, MT(ASCP), CIC
Infection Preventionist Consultant
Objectives
• Explain how to calculate an SSI rate
• Explain how to complete NHSN SSI forms using CDC
definitions and protocols
• Apply case definitions of procedure-associated
infections to case studies
Choosing Procedures to
Monitor
High Volume
Requirements
High Risk
Sample 12 month Surveillance Plan Timeline
Jan
Feb
Mar
Apr
May
• CLABSI
• SSI - HPRO
• Surgical ABX
Prophylaxis
Jun
• CLABSI
• SSI - HPRO
• Surgical ABX
Prophylaxis
• HCW
Influenza
Vaccine
• CLABSI
• SSI - KPRO
• Surgical ABX
Prophylaxis
• HCW
Influenza
Vaccine
• CLABSI
• SSI - HPRO
• Surgical ABX
Prophylaxis
• HCW
Influenza
Vaccine
• CLABSI
• SSI - KPRO
• Surgical ABX
Prophylaxis
• HCW
Influenza
Vaccine
• CLABSI
• SSI - KPRO
• Surgical ABX
Prophylaxis
Jul
Aug
Sep
Oct
Nov
Dec
• CLABSI
• SSI - HPRO
• Surgical ABX
Prophylaxis
• CLABSI
• SSI - KPRO
• Surgical ABX
Prophylaxis
• CLABSI
• SSI - HPRO
• Surgical ABX
Prophylaxis
• CLABSI
• SSI - KPRO
• Surgical ABX
Prophylaxis
• HCW
Influenza
Vaccine
• CLABSI
• SSI - HPRO
• Surgical ABX
Prophylaxis
• HCW
Influenza
Vaccine
• CLABSI
• SSI - KPRO
• Surgical ABX
Prophylaxis
• HCW
Influenza
Vaccine
Denominator for
Procedure
1. The reporting period is
one month
2. Collect a procedure
record for every
procedure that was done
during that month
For example, if you plan to monitor
KPRO procedures in July and 43
KPRO operations are done in July,
then you should collect details with
risk factor data on each of the 43
cases.
Terms and Definitions
• The data you report must
use exactly the same
terms and definitions
–
–
–
–
Inpatient
Outpatient
Operative Procedure
Operating Room
Additional terms will be added as we
specifically discuss SSI and PPP
Definition: Inpatient
A patient whose date of admission to the
healthcare facility and the date of discharge are
different calendar days.
Definition: Outpatient
A patient whose date of admission to
the healthcare facility and the date of
discharge are the same day
Definition: Operative
Procedure
A procedure that
1. is performed on a patient who is an
inpatient or an outpatient
2. takes place during an operation where a
surgeon makes a skin or mucous
membrane incision (including the
laparoscopic approach) and primarily
closes the incision before the patient
leaves the operating room
3. is represented by an Operative
Procedure Code
NHSN Operative
Procedure Codes
Each NHSN operative procedure category is defined by a
group of ICD-9-CM codes
NHSN Operative
Procedures
When an NHSN Operative Procedure is
selected for monitoring, all the procedures
within that category must be followed
CBGC -- Coronary artery bypass graft with only a chest
incision (mammary donor site)
CBGB – Coronary artery bypass graft with two incisions –
chest incision and donor site (usually leg)
These procedures are
mutually exclusive for a single
trip to the OR.
A patient can never have
both!
Definition: Operating
Room
• A patient care area that meets the
American Institute of Architects (AIA)
criteria for an operating room
• May include:
• Traditional operating room
• C-section room
• Interventional radiology room
• Cardiac cath lab
Duration
Duration:
Record the hours and
minutes between the
skin incision and skin
closure.
Do not record
anesthesia time!
Additional Rules about
Duration
• If more than one NHSN operative procedure is done
through the same incision during the same trip to the
OR, create a record for each procedure and use the
total time for the duration of both
Example: Mr. Jones goes to the OR and has a coronary
artery bypass graft with a [leg] donor site (CBGB) and
also a mitral valve replacement (CARD). The time from
the first incision until skin closure is 5 hours. A
Denominator for Procedure record is completed for the
CBGB and another for the CARD. The duration for each
is recorded as 5 hours and 0 minutes.
Additional Rules about
Duration
• If the patient goes to the OR more than once during
the same admission and another procedure is
performed through the same incision within 24 hours
of the original incision, report the combined duration
of operation for both procedures
Example: Fred Smith had a small bowel resection done on Tuesday morning which
had a duration of 3 hours and 10 minutes. On Tuesday evening, he was returned to
the OR where an exploratory laparotomy (XLAP) was done through the same incision
to repair a leaking anastamosis. The XLAP cut time was 1 hour and 10 minutes.
The Duration for each procedure – SB and XLAP -- is reported as 4 hours and 20
minutes
Wound Class
Wound class is an assessment of the likelihood and degree
of contamination of a surgical wound at the time of the
operation
C = Clean
CC = Clean Contaminated
CO = Contaminated
D = Dirty
Wound Class
Clean
 Uninfected wound with no inflammation
 Respiratory, alimentary, genital or uninfected urinary tract are not
entered
 Primarily closed
 Closed drainage, if needed
Clean-Contaminated
 Respiratory, alimentary, genital, or urinary tracts entered under
controlled conditions and without unusual contamination
Include operations on biliary tract, appendix, vagina, oropharynx if no
evidence of infection or major break in technique
Wound Class
Contaminated
 Open, fresh, accidental wounds
Major breaks in sterile technique or gross spillage from the GI tract
Includes incisions into acute, nonpurulent inflamed tissues
Dirty
 Old traumatic wounds with retained devitalized tissue
Wounds involving existing clinical infection or perforated viscera
Wound Class Cases
Case
Susanne undergoes an appendectomy following 2 days of acute abdominal pain
with rebound tenderness. At the end of the case, the surgeon indicates that
the appendix had ruptured and the surgical area was irrigated and keflex was
ordered for 3 days postoperatively.
Fred has a cholecystectomy using a laparoscopic technique. The gallbladder
was removed successfully with no breaks in operative asepsis.
George has a KPRO revision. When the surgeon makes the incision into the
surgical site, she notes that the knee joint demonstrates purulent matter and
inflammation. A specimen is obtained and sent to the laboratory which grows
S. aureus (MSSA).
Wound Class
3
2
4
ASA Class
An assessment score by the anesthesiologist of the patient’s preoperative
physical condition using the American Society of Anesthesiologists
Classification of Physical Status schema
1. Normally 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
Implant
Implant: A nonhuman-derived object, material, or
tissue that is permanently placed in a patient during
an operative procedure and is not routinely
manipulated for diagnostic or therapeutic purposes.
Examples include: porcine or synthetic heart valves,
mechanical heart, metal rods, mesh, sternal wires,
screws, cements, and other devices. Also includes
surgical clips and staples left in permanently.
Ella Baxter underwent a CBGB
(coronary artery bypass graft
with a leg donor site). During
the same operation, she had a
mitral valve replacement
(CARD)with a porcine valve.
Did Ms. Baxter’s procedure
include an implant?
Did Ms. Baxter’s procedure
include a transplant?
Surgical Site Infection
(SSI)
Introduction
• SSI occurs in 2 – 5% of patients
undergoing inpatient surgery in
the U.S.
• Approximately 500,000 each
year
• Each SSI is associated with
approximately 7-10 additional
postoperative hospital days
• Attributable cost estimates of SSI
range from $3,000 - $29,000
each
Minimum SSI
Surveillance
• Review of patient and laboratory records during the
patient admission
• Review of surgical patient readmissions
• Microbiology data from postoperative wound
cultures
SSI Post-discharge
Surveillance
Post-discharge surveillance
methods may also include:
• Examination of patient surgical
site during follow-up visits to
physician office or surgery clinic
• Surgeon surveys by mail or phone
• Review of medical records for
postoperative visits
The definition of the
specific SSI must be
met for any
methodology used!
SSI Definitions
Superficial
Incisional
• SIP
• SIS
Deep Incisional
• DIP
• DIS
Organ/Space
•
•
•
•
•
•
•
•
BONE
BRST
CARD
DISC
EAR
EMET
ENDO
etc.
Superficial Incisional SSI
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site
infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol
1992;13(10):606-8.
Superficial Incisional SSI
SIP and SIS
Superficial incisional primary (SIP)
A superficial incisional SSI that is
identified in the primary incision in
a patient that has had an
operation with one or more
incisions (e.g., C-section incision or
chest incision for coronary artery
bypass graft with a donor site
[CBGB])
Superficial incisional secondary
(SIS)
A superficial incisional SSI that is
identified in the secondary incision
in a patient that has had an
operation with more than one
incision (e.g., donor site [leg]
incision for coronary artery bypass
graft with a donor site [CBGB])
Example
Gretchen Dale delivers a baby by C-Section on August
23. On her 2-week postpartum visit to her surgeon, she
notes yellow purulent drainage in the superficial
incision.
Does Gretchen have a surgical site
infection?
Is it a superficial SSI?
Is it an SIP or an SIS?
Deep Incisional SSI
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site
infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol
1992;13(10):606-8.
Deep Incisional SSI
DIP and DIS
Deep incisional primary (DIP)
A deep incisional SSI that is
identified in the primary incision in
a patient that has had an
operation with one or more
incisions (e.g., C-section incision or
chest incision for coronary artery
bypass graft with a donor site
[CBGB])
Deep incisional secondary (DIS)
A deep incisional SSI that is
identified in the secondary incision
in a patient that has had an
operation with more than one
incision (e.g., donor site [leg]
incision for coronary artery bypass
graft with a donor site [CBGB])
Examples
Charles has purulent drainage from the chest incision
following a coronary artery bypass graft with a donor
site from the left leg. He also has redness and pain at
the leg incision. The doctor opens and drains the
incision. No culture is done for either site.
How should this be reported to NHSN?
A. SIP
B. SIS
C. Both
D. Neither
Organ/Space SSI
Specific event
types that must
be used to
differentiate
organ/space SSI
BONE
Osteomyelitis
JNT
Joint or bursa
BRST
Breast abscess/mastitis
LUNG
Other infections of
respiratory tract
CARD
Myocarditis/
pericarditis
MED
Mediastinitis
DISC
Disc space
ORAL
Oral cavity
EAR
Ear, mastoid
OREP
Other respiratory
EMET
Endometritis
OUTI
Other urinary
ENDO
Endocarditis
SA
Spinal abscess
EYE
Eye, other than
conjunctivitis
SINU
Sinusitis
GIT
GI tract
UR
Upper respiratory
IAB
Intraabdominal, NOS
VASC
Arterial or venous
IC
Intracranial
VCUF
Vaginal cuff
Organ/Space SSI
http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf
has had more
than one operation…
If a patient has several NHSN
operations prior to an SSI,
report the operation that was
performed most closely in
time to the infection date
Example: Mr. Smith underwent a SB on 12/02/2011. Three days
later, he went back to surgery to repair a leaking anastamosis (OTH).
He developed an intraabdominal abscess on 18/03/2011. This SSI is
attributed to the second procedure (OTH), not the SB
Example
Robert Jones undergoes a coronary artery bypass
graft (CBGB) in which the surgeon obtained a donor
vessel from a site in Robert’s left leg.
5 days postoperatively, Robert had pain and edema
in the leg incision. The surgeon opened the
superficial incision, drained the pus, and irrigated
the wound.
Does Robert have a superficial
incisional SSI?
Is it a SIS or SIP?
SSI – Event Details
Select the specific elements of the
definition that were used to identify
this infection
Secondary BSI
• A culture-confirmed BSI associated with a
documented HAI at another site
• If a primary infection is cultured, the Secondary BSI
must yield culture of same organism and exhibit the
same antibiogram as the primary HAI site
Example: Mrs. Jones grows E. coli in her urine (>100,000 col/cc)
and in her blood. Both organisms have the same antimicrobial
susceptibility pattern. The UTI is reported with a secondary BSI.
Example: Mr. Smith grows A. baumanii in his surgical wound which is
resistant to amikacin and levofloxin but sensitive to other tested
antimicrobials. He is also growing A. baumanii in his blood, but it is
susceptible to amikacin.
Secondary BSI (cont.)
• If an infection is identified and no culture is used to
meet the infection criteria and a blood culture is
positive, then the first infection is considered primary
and the bloodstream infection is reported as
secondary. The organism cultured from the blood is
reported as the organism for the primary site.
Example: 6 days postoperatively, Miss Green has an abdominal
abscess, confirmed by CT scan. On the same day, her blood is
drawn and grows Bacteroides fragilis. The infection is reported as
an SSI-GIT (organ space SSI) with a secondary BSI. The organism is
reported as B. fragilis
Mr. Fuentes has a central line for
infusion of fluids during a complex
abdominal procedure and the blood
culture grows Bacteroides fragilis on
the 4th postoperative day. His surgeon
states that the BSI is secondary to the
operation – he says there was
probably a small leak in the
anastamosis.
Does Mr. Fuentes have a secondary
BSI?
A. Yes, the primary infection is SSI-IAB
B. Mr. Fuentes has both a CLABSI and an SSI-IAB
C. Mr. Fuentes has a CLABSI – not secondary to an SSI
SSI Rate
* Stratify by:
•Type of NHSN operative procedure
•Basic NHSN Risk Index
NHSN Basic Risk Index
•The index used in NHSN assigns surgical patients into
categories based on the presence of three major risk factors:
The patient’s SSI risk category is simply the number of these
factors present at the time of the operation
Example of NHSN Risk
Index
Elements
Operation >
duration cut
point
Wound class
ASA Score
Risk Index
Category
Patient #1
Yes
IV
4
3
Patient #2
No
I
1
0
Patient #3
Yes
II
1
1
2008 NHSH Report – SSI
Rates
George Bolthouse, 51
• The patient has an aortic aneurysm repair (AAA) surgery and
is discharged, then comes back about a week later with
peritonitis. A needle aspiration of purulent material from
the abdomen grows P. aeruginosa. The surgeon attributes
the peritonitis to a perforated diverticulum.
Should this be counted as a surgical site infection
associated with the AAA?
A. Yes – this is an organ/space SSI (IAB)
B. No, a perforated diverticulum is a complication of the
surgery, not an infection
Tom Jones, 32
• Mr. Jones is a post op hernia (HER) patient that was
seen in the ER 6 days post op with a large cellulitis, a
pain level 10/10, swelling, tenderness, and redness.
He was admitted for treatment with antibiotics. He
had leukocytosis and an elevated CRP (199). Serous
drainage from the incision was no growth.
Is this a superficial incisional or a deep incisional
SSI?
A. Superficial incisional SSI
B. Deep incisional SSI
C. Neither – the surveillance criteria for SSI are not met
Bruce Keller
• Patient underwent a
KPRO procedure at
our hospital
• The patient was
discharged to a
Is this an SSI? Should it
rehab facility and
be reported?
sustained a fall one
As long as there is no indication
week later
that the wound dehisced
• The incision dehisced because it was infected, it would
and became infected not be reported.
Mary Blair, 77
• Patient had a hip prosthesis procedure (HPRO) on 2/4/08. She
had an infected AV dialysis graft rupture on 7/6/08 – blood
cultures grew Staph aureus and she was placed on antimicrobials
for treatment of the bloodstream infection. On 7/21/08, Jane
experienced pain in the hip joint – radiographic evidence on
gallium scan shows an abscess at the hip prosthesis site– culture
of hip was no growth.
Should this be counted as a SSI associated with the HPRO if the
AV graft was the primary infection and it appears that the hip
became seeded secondarily?
A. Yes, this is an SSI
B. No, this infection is secondary to the bloodstream infection
Question?
• Which of the following does not meet the criteria for
a superficial incisional SSI if identified within 30 days
after the procedure?
A. Culture of fluid obtained from superficial incision
grows MRSA
B. Physician documents “superficial surgical site
infection” in patient record
C. Purulent drainage noted from superficial incision
D. Physician documents “cellulitis” at incision site
What do you do about high rates?
•
•
•
•
Share data with surgeons either way (High or Low)
Type of surgery
Same surgeon, OR room, etc
Surveillance methods
– Extensive vs minimal.
• Look at SCIP measures
– Prophylactic ABX
• Timing important
• Is MRSA a problem?
• Are doses weight based?
• Look at other pre op measures
• Post op measures