Today’s Webinar will begin at 11 PST
11/29/12
Do You Speak SIR? Using your SSI
SIR data to drive improvement
November 29, 2012
Introduction
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mute function or *6
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Using Data to
Drive
Improvement
On Death, Dying & Data
ACCEPTANCE
DEPRESSION
BARGAINING
ANGER
DENIAL
Connie Cutler, RN, MS, CIC, FSHEA
Main Line Health
Bryn Mawr Hospital
Lankenau Medical Center
Paoli Hospital
Riddle Hospital
7
NHSN’s Definition of a SIR
8
Standardized Infection Ratio
SIR =
Observed (by IP Surveillance)
Expected (by NHSN)
Standardized Infection Ratio
Simple MATH (a fraction)
Observed (# SSIs found through surveillance)
Expected (# SSIs that NHSN predicted)
• It’s all about comparison to the number 1
• SO, if Observed = Expected, result is 1 and that means SIR
is equal to (same as) CDC’s National Healthcare Safety
Network
10
Standardized Infection Ratio
• If surgery or surgeon is less than ONE, there are
less SSIs than the comparative NHSN database
• If higher than ONE, there are more SSIs than the
comparative NHSN database
• How much more? Depends on number…
– 0.9 = 90% of expected OR 10% better than NHSN
– 1.4 = 140% of expected or 40% worse than NHSN
– 1.0 = 100% of expected or same as NHSN
11
End of Quality Year Dashboard (April 2011-March 2012)
Numerators (infections) and Denominators (cases) for 6 procedures have been required by
PA to be reported through the CDC’s National Healthcare Safety Network (NHSN).
Colon Surgeries have been added for 2012.
12
12 Months of SIRs
Numerators (infections) and Denominators (cases) for 6 procedures have been required by
PA to be reported through the CDC’s National Healthcare Safety Network (NHSN).
Colon Surgeries have been added for 2012.
New Dashboard
Infection Prevention is providing data on these 26 procedures
Numbers of Surgeries with SIRs
•
•
•
Cardio-Thoracic Surgery Procedures
– Cardiac Valve
– CABG with one incision
– CABG with two incisions
General Surgery Procedures
– Appendectomy
– Lap Cholecystectomy
– Open Cholecystectomy
– Lap Colectomy
– Open Colectomy
– Exploratory Abdominal Surgery
– Vascular Bypass Surgery
– Vascular Graft/Fistula/AV Shunt
OB/GYN Categories
– Cesarean Section
– Abdominal Hysterectomy
– Vaginal Hysterectomy
•
•
•
•
Orthopedic Categories
– Laminectomy
– Knee Prosthesis
– Hip Prosthesis
Neurosurgery Procedures
– Laminectomy
Plastic Procedures
– Breast Implant
– Breast Lumpectomy
– Mastectomy
Specialty Categories
– Esophageal Resection
– Kidney Transplant
– Lung Resection
– Pacemaker
– Pacemaker/ICD Insertion
15
Goal: Zero SSIs
• We have committed to
–implementation of evidence-based
“bundles” for all patients undergoing
surgical procedures
• special focus on cardiac and
orthopedic
–Feedback on SIR is provided to
surgeons quarterly
16
Accomplishments
• Infection Prevention  system &
division chiefs of surgical specialties
–explain SIR
–distribute surgeon-specific data
–discuss best practices
Accomplishments
• Individual hospitals continue to address
issues where their SIR is above NHSN‘s
benchmarks (1.0, 0.75, 0.5 are our 3
goals)
Risk-Stratification
19
Surgeon-Specific SIR Report
20
Two examples of SIRs
21
Two examples of SIRs
22
Total Hips/Knees SIRs for 3+ years
26
Vicky Brinsko, Director IP
Vanderbilt University
Leaping Into Surgical SIR’s
Moving to SIRs
• Big Changes from CDC/NHSN and CMS
• In Jan 2012, CMS requires reporting of
SSIs from Colon Surgery (COLO) and
Abdominal Hysterectomy (HYST) as part
of their pay for performance program
• Up until this point CDC via NHSN was
providing benchmarks for “comparison”
to a pooled mean
• In January 2012, CDC switched to SIRs
for SSIs
Anticipating Change
i n fec ti on c o nt rol a n d h o spi ta l e p idem i olo gy
o cto be r 2 011, v o l. 3 2, n o . 1 0
original article
Improving Risk-Adjusted Measures of Surgical Site Infection
for the National Healthcare Safety Network
Yi Mu, PhD;1 Jonathan R. Edwards, MStat;1 Teresa C. Horan, MPH;1
Sandra I. Berrios-Torres, MD;1 Scott K. Fridkin, MD1
Infect Control 2006;27:1330–1339. Hosp Epidemiol 2002;23:372–376.
• At VUMC we knew this change was coming
• We began preparing our surgeons for this change in late
2011
– Baby steps
– Announced in November 2011 that VUMC easing in to SIRs for
surgical infection data reporting
Standardized
Infection Ratio (SIR)
• Ratio of observed events to expected events
• Expected events =
The expected number CDC calculates in NHSN
• SIR = 1  infection rate at benchmark
• SIR < 1  infection rate lower than benchmark
• SIR > 1  infection rate higher than benchmark
Overall
SIR
P-CARD
SIR
COLO SIR
FUSN SIR
CBGB SIR
HYST SIR
KPRO SIR
P-VSHN
SIR
REC SIR
CRAN SIR
CBGC SIR
VHYS SIR
Future
Metrics
HPRO SIR
P-FUSN
SIR
VSHN SIR
CARD SIR
CSEC SIR
Future
Metrics
Summary Data
SSI Rate
Overall SIR
6
2.5
5
2
Surgical SIR
4
3
2
1
1.5
1
0.552
0.5
0
0
SSI Rate
Linear (SSI Rate)
Overall SIR
CDC Benchmark
Linear (Overall SIR)
Are the Data Risk Stratified?
Description
Procedure
code
Abdominal aortic aneurysm
AAA
Limb amputation
AMP
Appendectomy
APPY
Arteriovenous shunt for dialysis
AVSD
Bile duct, liver or pancreatic surgery
BILI
Breast surgery
BRST
Coronary artery bypass graft
CABG
duration
Cardiac surgery
CARD
Carotid endarterectomy
CEA
Cholecystectomy
CHOL
Colon surgery
COLO
duration
Craniotomy
CRAN
Cesarean delivery
CSEC
class, emergency
Spinal fusion
FUSN
List of variables
Emergency, wound class, ASA score, duration
Bed size, duration
Emergency, endoscope, gender, ASA score, wound class
Age, duration
Emergency, endoscope, ASA score, wound class, bed size, duration
ASA score, bed size, duration
Anesthesia, gender, medical school affiliation, ASA score, bed size, age,
ASA score, wound class, age, duration
Emergency, endoscope, ASA score, wound class, age, duration
Anesthesia, endoscope, gender, ASA score, wound class, bed size, age,
Trauma, bed size, age, duration
Body mass index, age, anesthesia, ASA, duration, labor, bed size, wound
Anesthesia, gender, medical school affiliation, trauma, wound class,
diabetes,
Infect Control Hosp Epidemiol 2011;32(10):970-986
Monthly Reports to Surgery
• We provide monthly
reports of surgical
data to the Pod
Leaders (see example)
• We present these
data as a summary in
the Perioperative
Surgical Enterprise
meeting
Fictional data used for illustration purposes
New Reporting Metrics
• In July (beginning of our
fiscal year), we
presented a tandem
report
• This report had the
“old” graph they were
used to seeing (without
the CDC benchmark
featured)
Fictional data used for illustration purposes
New SIR Addition
Infections per 100 procedures
SSI Infections Rates for Pod 1 Abdominal Hysterectomy
Hysterectomy Infection Rates
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
4.9
2.8
2.4
0.7
Abd Hyst
Upper Limit
Average
Lower Limit
Linear (Abd Hyst)
SSI-Rate: Number of patients with surgical
site infection per 100 procedures. The rate
reflects the number of CDC defined Surgical
Site Infections divided by the number of
cases selected by ICD-9 Procedure Code.
Standardized Infection Ratio (SIR): The risk
adjusted calculation comparing observed
infections to predicted infections;
standard=1
>1 worse than expected
<1 better than expected.
Upper Limit: One Standard deviation above
the mean (average).
Analysis:
Mean (average): Sum of a list of infections
divided by total number of procedures.
The overall rate displays a downward trend. The Upper Limit is 4.9 infections per
100 procedures. The 2008 CDC benchmark is 4.1 infections per 100 procedures. The
Vanderbilt mean (blue line) is 2.8 infections per 100 procedures The Lower Limit is
0.7 infections per 100 procedures. The infection rate for 2012 Quarter 3 is
incomplete 2.4 infections per 100 procedures.
Lower Limit: One Standard deviation below
the mean (average).
The new risk-adjusted Standardized Infection Ratio (SIR) for the identical time
period is represented in the graph below. The national benchmark is 1.0. The
Centers for Disease Control and Prevention calculates the SIR individually for each
procedure and provides an expected number of events based on the specific risk
makeup of the denominator population. The variables included in the Abdominal
Hysterectomy risk model are anesthesia, endoscope, ASA score, wound class, and
duration of surgery.
The SIR for Hysterectomy 2012Q3 is 1.017 which is not different than 1.
3
2.5
2
1.5
1
0.5
0
Standard Deviation: A measure of the
variation of the observations
Methodology: All cases for ICD-9 codes are
reviewed using CDC-defined surveillance
procedures
KEY REPORTING COMMITTEE:
Perioperative Enterprise Committee,
OR POD Reports
DATA SOURCE: Medipac coding data and
manual chart review by infection
preventionists.
HYST SIR
Infection Preventionist Assigned:
Tracy Louis RN, MSN, CIC
1.017
HYST SIR
CDC Benchmark
Linear (HYST SIR)
DEFINITIONS: Vanderbilt Infection Control and Prevention follows the CDC
definitions for surgical site infections. These definitions are available at
www.cdc.gov/nhsn.
CDC-Defined Procedure Type:
HYST: Abdominal hysterectomy. Removal of uterus through an abdominal incision.
HYST ICD-9 Procedure codes captured:
68.31,68.39,68.41,68.49,68.61,68.69
• We included both the
altered familiar graph
and the new SIR graph
with an explanation
• Surgeons are visual and
having both graphs in
tandem was helpful
Change is Good
Amy Nichols, RN, MBA, CIC
Using NHSN’s Standardized
Infection Ratio
The UCSF Experience
Amy Nichols, RN, MBA, CIC
Amy Nichols, RN, MBA, CIC
Director
Hospital Epidemiology and
Infection
Control
November 2012
What is the Standardized Infection Ratio?
• Observed/Expected events
– Expressed as decimal
– Accompanied by significance statistics
– Calculated by National Healthcare Safety Network
database
• Calculations are based upon the 2009 NHSN report (data from 2006-2008)
• 2009 report reflects information reported from about 600 reporting
hospitals
• Now, NHSN has about 4500 reporting hospitals
42
SIR at UCSF
• Initially calculated quarterly for Surgical Site
Infection (SSI) reports, now rolling monthly
• Annually reported for Device-Related Infection
(DRI) surveillance reports
– Central Line-Associated Bloodstream Infections
(CLABSI)
– Catheter-Related Urinary Tract Infections (CAUTI)
– Not reported for Ventilator-Associated Pneumonia
(VAP)
43
UCSF SSI SIR Display
CATEGORY
# Procedures
# SSI
Rate
SIR*
P-Value
95% CI
Abdominal Aortic
Aneurysm
27
0
0.00
0.000
0.2415
2.596
0.4034
0.149,
2.109
0.0005
0.336,
0.795
Appendectomy
Biliary Surgery
44
222
397
3
23
1.35
5.79
0.722
0.530
UCSF CLABSI SIR Display
45
UCSF CAUTI SIR Display
46
SIR-Based Strategy Implementation
• SSI
– Focus away from abdominal and transplant surgeries
– Focus on procedures with SIR >1
– No procedures were significantly above expected
• CLABSI
– Reduction strategic work plan unchanged
– No different than expected, but events still occur
– Irreducible minimum achieved?
• CAUTI
– Reduction strategic work plan unchanged
– Rates reducing
47
Upcoming Beyond SCIP Events
•
•
•
•
•
Join us for a FREE Webinar
December 18, 2012
11:00 AM - 12:00 PM
Sue Barnes from Kaiser Permanente
SSI Prevention: How we are doing based on
direct IP observations
• www.cynosurehealth.org
www.cynosurehealth.org
Thanks for joining us today