Scottish Surveillance of Healthcare
Associated Infection Programme
SURGICAL SITE INFECTION
SURVEILLANCE
Training for data management,
quality assurance and reporting
Role of HPS
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
Objectives:
Scottish Surveillance of Healthcare
Associated Infection Programme
• To describe and apply all data
management points pertinent to the
local and national management of data
• To apply quality assurance requirements
to SSI surveillance data
• To develop reporting and mechanisms of
feedback for surgical site infection data
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)
Objectives of surveillance
• Early warninginvestigation of
problems and intervention to
control
• Monitoring trends
• Examining impact of interventions
• To gain information on quality of
care
• Targeting resources
Scottish SSI Surveillance Programme
- The Surveillance Cycle
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 or fax*
Data scanned at HPS
and database with
reporting facilities
fedback to hospital
within 3 months
Electronic data
transfer to HPS*
Collated for national
reporting of SSI
surveillance
National Report
Results fed
back to
hospitals
Scottish Surveillance of Healthcare
Associated Infection Programme
SURGICAL SITE INFECTION
SURVEILLANCE
Data Management
Aims of SSIS Programme
Scottish Surveillance of Healthcare
Associated Infection Programme
• Collect surveillance data on SSI’s to permit
estimation of the magnitude of SSI risks in
hospitalised patients
• Analyse and report SSI surveillance data and
describe trends in infection rates
• Provide timely feedback of SSI rates to
assist surgical units in minimising the
occurrence of SSI’s
Data Management
What data?
Each Division should undertake surveillance
Scottish Surveillance of Healthcare
on at least two of the following operation
Associated Infection Programme
categories, hip arthroplasty & caesarean
section must be undertaken if performed at
site.
Generic
Cardiac Surgery, CABG, Abdominal
Hysterectomy, Caesarean Section,
Major Vascular Surgery, Breast
Surgery, Cranial Surgery.
Orthopaedic
Hip Replacement,
Operations for Fractured Neck of
Femur, Knee Replacement.
Data Management Process
Data Collection
Checking for Completeness
and Accuracy
Data Input
Quality Assurance
Checking
‘Local’ Reporting
‘National’ Reporting
Alternative Data Management
Scenarios
•
•
•
•
‘Local’ Data Management
Data Management at HPS
Data Transfer
The SSIS Database
Scottish Surveillance of Healthcare
Associated Infection Programme
Quality Assurance Workshop
Scottish Surveillance of Healthcare
Associated Infection Programme
• Collect completed forms
• Check forms for completeness and
accuracy
• Process the data into the database
• Carry out QA Checking
• Present your findings
Scottish Surveillance of Healthcare
Associated Infection Programme
SURGICAL SITE INFECTION
SURVEILLANCE
Ensuring valid and reliable data
through quality checks
AIM
Scottish Surveillance of Healthcare
Associated Infection Programme
• To promote valid and reliable
data by performing thorough
and appropriate quality checks
Objectives:
Scottish Surveillance of Healthcare
Associated Infection Programme
• To recognise the importance of
appropriate data quality checks – both
locally and nationally
• To understand how to perform quality
checks on different aspects of data
entry
• To be aware of the consequences of
poor quality data
What would you look for in a
quality product?
• A quality product is
important to us all, SSI
surveillance data is no
different
• A lot of time and effort is
put in by many people
towards SSI surveillance
data to ensure it is:
– Valid
– Reliable
• Everyone must have
confidence in the data –
that what is presented is
a quality product !
Consequences of poor quality data
• Unreliable, invalid and
subsequently inaccurate data
• Subjective outcome(s)
• Waste of time !
Consequences of poor quality data
• Overestimated infection rates
• Underestimated infection rates
• Inappropriate change to evidence based
practice
• No change to practice / infection rates !
Implications for Divisions
• Clinical Governance Agenda
• Quality Improvement Standards (CSBS)
• Performance Assessment Framework
• National Reporting
• Public Concern
The “5 Ws” for quality
• What – SSI surveillance data
• Who – local and national teams
• When – frequency of data
collection,collation and feedback
• Where – local and national teams
• Why – to ensure valid and reliable
data
Quality checks
• Manual/visual checks
• Automated Form Processing
• Standard queries within Microsoft
Access database
Manual/visual quality checks
• Data collection forms returned for
collation to local co-ordinator
– Forms visually checked for:
• Completeness
• Accuracy
– Cleaning of data
– Locating missing data
• Perform at least monthly, to avoid backlog
• Denominator checks also performed at this
time, e.g. through theatre lists
• Essential to ensure data are accurate
before sending to HPS and compiling
reports for local feedback
•
•
•
•
•
What
Who
When
Where
Why
Manual / visual quality checks
• Forms are received by SSHAIP team
(HPS) from divisions (monthly)
• QA protocol is followed - forms are
checked for:
– Completeness
– Accuracy
• Cleaning of data
• Locating missing data
•
•
•
•
•
What
Who
When
Where
Why
AFP quality checks
• Forms scanned (within the quarter)
• ‘Validation rules’ (within Teleform)
– Locating missing data
• Verification of fields prompted
– SSHAIP team verify queries
• 1st 100 forms verified field by field
to be confident in level of accuracy
• Thereafter, monthly 10% of forms
randomly checked field by field
•
•
•
•
•
What
Who
When
Where
Why
Validation Rules
• Entries required
• Date frames set, e.g. age,
date of admission, date of
operation
• Time frames set, e.g.
start time of operation,
completion time of
operation, date of
confirmed SSI
MS Access Standard Query Quality Checks
• Standard queries written
include:
– Lookup tables, e.g.
hospital codes, OPCS4
codes
– ‘Value’ checks, e.g. sex,
category of procedure
– Date, time and value
frames set, e.g. date of
operation, BMI
– Accuracy checks, e.g.
criteria for SSI and
when SSI detected against SSI present
and date frames
•
•
•
•
•
What
Who
When
Where
Why
• Queries run and
verified (e.g.monthly)
by SSHAIP team
• Anomalies checked,
contact with local coordinator
Additional QA checks
• Annual case note
review
– 20 random case
notes reviewed
against database
– SSHAIP team and
local co-ordinators
• Permission for
access
– A report will be
fedback to all
divisions
•
•
•
•
•
What
Who
When
Where
Why
• Denominator checks
– In addition to
division
denominator
checks the
SSHAIP team will
liaise with ISD to
obtain
denominators by
hospital by
procedure
Summary
• The importance of understanding:
– The processes for data entry
– The many data quality checks
– The responsibilities for quality
checks, both locally and
nationally
– The consequences of poor
quality data
Data Reporting Workshop
• Workshops to:
– Be familiar with reports that can
be obtained through MS Access
database
– Consider use of these reports for
the local feedback process
– Raise any issues with these
reports
– Analyse reports to ensure they
provide valid and reliable data
Reporting data
Reporting of data
Objectives:
• To develop an understanding of the
local and national mechanisms of
reporting SSI data
• To describe risk adjusted reporting
• To examine the different
mechanisms which can be utilised
for reporting data
Reporting ?
Requirements for successful
surveillance
• Commitment of senior managers
• Commitment of a multidisciplinary
staff
• A suitable method for data
collection
• A suitable method for reporting
The “5 Ws” of data reporting
• What ?
• Who ?
• When ?
• Where ?
• Why ?
What ? – Feedback of data
• Graphs
• Tables
• Descriptive
statistics
• Inferential
statistics
What ?
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 score>=3
– Wound classified as contaminated or dirty
– Duration of operation
NNIS Risk Index Graph
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
120%
45%
41%
100%
100%
100%
80%
78%
60%
50%
40%
9%
5%
SSI Rate (%)
Percent Operations
Percentage of Operations & SSI rate by NNIS Score
% Operations
SSI Rate
20%
0%
0
1
2
NNIS Score
3
EXI
T
Who? – Presenting the data
• All stakeholders: All
multidisciplinary
involved in the surgical
care pathway
– Surgeons
– Infection control
staff
– Managers/
resources
– HPS
When ?
• Regular feedback:
– Active
– Passive
• Denominator
• At least quarterly
Where ?
• Locally: by individual
(anonymised)
• Nationally: HPS
collate and present
by Division
Why ?
• Prevention (Haley et al)
– Engaged clinicians
– Motivated Infection control staff
– Intensive surveillance programme
• Hawthorne effect
• Early identification of problem
trends/ outbreaks
• Resource allocation
Month
Nov '98
Oct '98
Sep '98
Mar '98
Feb '98
Jan '98
Dec '97
Nov '97
Oct '97
Sep '97
Aug '97
July '97
June '97
May '97
Apr '97
Mar '97
Feb '97
Jan '97
Dec '96
Nov '96
Oct '96
Sep '96
Aug '96
Jun/Jul '96
May'96
6
Apr '96
Mar '96
Feb 96
Jan 96
Dec 95
Nov 95
% infected
Percentage of clean wounds infected per month
20
18
16
14
12
10
8
Moving average based
on last 6 months
4
2
0
Surgical Wound Infection Rate over by Audit Period
Surveillance Stopped
16.0%
14.3%
14.0%
13.2%
12.0%
11.1%
10.2%
% Infected
10.0%
8.3%
7.8%
8.0%
6.0%
4.0%
2.0%
0.0%
Baseline (Nov-Dec 95)
After Feedback to
Surgeons (Jan-May 96)
After Feedback to Wards
(June-Dec 96)
Before Cessation of
Surveillance (Mar 98)
After Cessation (Sep 98)
After Feedback
Recommenced (Oct-Nov
98)
Source: Dr Ed Smyth
Daily visits to
all surgical
wards to carry
out wound
checks
Wounds are
checked before
discharge from
hospital
Data are graphed and
fed back to the
surgeons, nurses and
infection control
team on a monthly
basis
Wound
surveillance nurse
administrates the
project
Wound surveillance
nurse identifies
patients from
theatre lists
Operative
details…completed
by wound
surveillance nurse
on the ward post op
Demographic
details…completed by
wound surveillance
nurse on the ward pre-op
Patients have a 24
hour answer
service telephone
number to call with
wound problems.
Primary care staff
also liaise with
wound surveillance
nurse
Data are managed
and collated by
the wound
surveillance nurse
Patients with
identified wound
problems are seen at
wound surveillance
clinics, or at home
by the wound
surveillance nurse
for wound review
Patients are seen at wound
surveillance clinics, or at
home by the wound
surveillance nurse at day
30 post-op for wound
review
Conclusion
• SSI rates are key quality indicators
for surgery
• Data must be complete
• Data must be reliable and valid
• Data must be reported back to
clinicians
• Data must be acted upon
Summary
• Overviewed data management issues
pertinent to the local and national
management of data
• Developed an understanding of the local
and national quality assurance
requirements
• Aware of the importance of reporting
and mechanisms of feedback of surgical
site infection data
www.hps.scot.nhs.uk