Surgical Site Infection Improvement Programme case studies (291

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Surgical Site Infection
Improvement Programme
Surveillance:
Case studies
Case 1
• A patient had bilateral knee prostheses (KPRO)
implanted during a single trip to the OR
– Left KPRO incision at 0823 and closed at 0950
– Right KPRO incision at 1003 and closed at 1133
Which statement is true
A. One KPRO procedure should be reported
with a combined duration of 2 hours 57 min
B. Two separate KPRO procedures should be
reported, each with a duration of 2 hours and
57 min
C. Two separate KPRO procedures should be
reported:
– L KPRO with a duration of 1 hour 27 min
– R KPRO with a duration of 1 hour 30 min
Correct Answer
C. Two separate KPRO procedures should be
reported:
—L KPRO with a duration of 1 hour 27 min
—R KPRO with a duration of 1 hour 30 min
Rationale
•
For operative procedures that can be
performed bilaterally during same trip to
operating room (e.g., KPRO), two separate
Denominator for Procedure forms are completed
•
To document the duration of the procedures,
indicate the incision time to closure time for
each procedure separately
•
If separate times are not known, take the
total time for both procedures and split it evenly
between the two
Case 2
• 18th July
– 45 year old man had a Total Hip Replacement
(HPRO)
• 22nd July
– Patients hip incision has purulent drainage from
subcutaneous tissue and slight erythema; incision
is intact.
– Wound drainage specimen sent to lab for culture
(24th July: grew S aureus)
– Patient started on antibiotics
What should be reported to NZ
surveillance
• Nothing – the surgeon did not open the
wound, so the criteria are
not met
• Nothing, It is an HAI but not an SSI
• Superficial SSI
• Deep SSI
Correct Answer
• Superficial SSI
Rationale
• 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:
a.
b.
c.
purulent drainage from the superficial incision
organisms isolated from an aseptically obtained culture of fluid or tissue
from the superficial incision.
superficial incision that is deliberately opened by surgeon and is culturepositive or not cultured,
and
d.
patient has at least one of the following signs or symptoms: pain or
tenderness, localised swelling, redness, or heat. A culture-negative finding
does not meet this criterion.
diagnosis of superficial incisional SSI by the surgeon or attending physician.
Case 2 (ii)
• 18th July
– 45 year old man had a Total Hip Replacement (HPRO)
• 22nd July
– Patients hip incision has purulent drainage from
subcutaneous tissue and slight erythema; incision is
intact.
– Wound drainage specimen sent to lab for culture (24th
July: grew S aureus)
– Patient started on antibiotics
What is the date of infection?
Answer
• 22nd July (when criteria first met i.e. purulent
drainage)
Case 3
• Patient is admitted to the hospital on 4th July for
elective surgery and active MRSA screening test is
positive
• On the same day patient undergoes Total knee
replacement (KPRO)
• Post operative course is unremarkable; patient
discharge on the 8th July
• On the 21st July patient is readmitted with complaints
of acute incisional pain since the day before. Surgeon
opened the wound to the fascial level and sent
drainage specimen for culture and sensitivities
• On 25th July, culture results are positive for MRSA
What infection should be reported?
• Superficial Incisional SSI
• Deep Incisional SSI
• Organ/space SSI
Answer
• Deep Incisional SSI
– Criterion b
Rationale
Infection occurs within 30 or 90 days after the operative procedure
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 by a
surgeon and is culture-positive or not cultured,
and
patient has at least one of the following signs or symptoms: fever (>38ºC),
localised pain or tenderness. A culture-negative finding does not meet this criterion.
c.
an abscess or other evidence of infection involving the deep incision that is
found on direct examination, during invasive procedure, or by histopathologic
examination or imaging test.
d.diagnosis of a deep incisional SSI by a surgeon or attending physician.
Case 4
• Patient has a THR (HPRO) performed on the 17th March at
Hospital A
• Discharged from Hospital A on 19th March
• Admitted to Hospital B on 25th March with purulent
drainage from the superficial incision
• Further investigation concludes this is a superficial
incisional SSI
•What should hospital B do?
•What should hospital A do?
•What if the infection became apparent 35 days after the
procedure?
Answers
• What should hospital B do?
– Notify Hospital A about the SSI
• What should hospital A do?
– Report the SSI to NZ surveillance
• What if the infection became apparent 35 days
after the procedure?
– Not an SSI; not reported
Rationale
•SSIs are always associated with a particular
operative procedure and with the facility in
which the operation was performed; in this
case, this was Hospital A
•Superficial SSI are followed for only 30 days
Case 5
• Patient admitted on the 9th October and
underwent a R THR; wound class – clean
• 13th Oct the patient has a temp 38.7oC and hip
pain. Ultrasonography shows abscess in the hip
joint
• 14th Oct the joint abscess is aspirated and the
specimen is sent for culture. Antibiotics started.
• 18th Oct patient is discharged from hospital on
oral antibiotics. Abscess is culture positive for
Staph aureus
What type of infection does this
patient have?
A.
B.
C.
D.
Superficial Incisional SSI
Deep Incisional SSI
Organ/space SSI
Does not meet criteria for any SSI
Answer
Organ/space SSI – joint
Organ/ Space SSI
Infection occurs within 30 or 90 days after the VICNISS 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,
and
Patient has at least one of the following:
a. purulent drainage from a drain that is placed into the organ/space.
b. organisms isolated from an aseptically obtained culture of fluid or tissue in the
organ/space.
c. an abscess or other evidence of infection involving the organ/space that is
found on direct examination, during invasive procedure, or by histopathologic
examination or imaging test.
d. diagnosis of an organ/space SSI by a surgeon or attending physician.
and
Meets at least one criterion for a specific organ/space infection site
Case 6
Day 1
HPRO performed. Patient screened for MRSA
upon admission as per local protocol
Day 2
Patient is very confused. Temperature normal.
Wound condition good
Day 3
Results of the admission screening cultures of
the nose and groin are positive for MRSA. The
following entry is found in the chart: “patient
removed dressing several times. Recurrent
confused condition. Wound edges very red and
taut”
Case cont…
Day 5
Entry in the chart: “wound abscess lanced by the
attending surgeon”. A wound specimen sent to
lab for culture. Antibiotics begun.
Day 7
Wound culture: MRSA
Day 9
Improvement in wound condition. Discharged to
rehab centre
Does this patient have an SSI?
If Yes, what type?
Answers
• Does this patient have an SSI?
– Yes
• If Yes, what type?
– Superficial incisional SSI
Rationale
•
Post-op patient has an intact incision or status of incision
is unknown (e.g., dressing never changed so no one has seen
the incision), or it is noted that patient showered/bathed “too
early” post-op, or it is noted that the patient was incontinent
and incision was or may have been contaminated, or patient
got intact incision dirty, then subsequent incisional infection is
considered an SSI.
Case 7
• A patient underwent a KPRO in April 2011
• In October 2012 the prosthesis was removed due to an
unresolved infection in the joint space with MRSA. A spacer
was placed and a replacement procedure was scheduled for
the following Feb 2013.
• The replacement KPRO was completed in Feb 2013 and,
within 3 weeks after discharge, he developed osteomyelitis
with MRSA near the attachment site
How should this osteomyelitis be
reported?
A. SSI linked to the April 2012 operative
procedure
B. SSI linked to the October 2012 operative
procedure
C. SSI linked to the Feb 2013 operative
procedure
D. Does not meet criteria for SSI
Answer
C.
SSI linked to the Feb 2013 operative procedure
Rationale
•
If a patient has several NZ SSI operative
procedures performed on different dates prior
to an infection, attribute the infection to the
operation that was performed most closely in
time prior to the infection date, unless there
is evidence that the infection was associated
with a different operation.
Case 8
• A female patient underwent a KPRO operation on
December 22nd 2012. She returned to her
surgeon on January 31st 2013 with purulent
drainage from the superficial incision, which had
started 2 days prior.
• How should this infection be reported?
A.
B.
C.
D.
SSI – superficial
SSI – Deep
SSI – Organ/Space
Not reported
Answer & Rationale
• Not reported – does not met criteria for SSI
• Infection occurred > 30 days post-op therefore cannot
be called SSI-superficial
• Not readmitted to hospital
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