Scottish Surveillance of Healthcare
Associated Infection Programme
SURGICAL SITE INFECTION
SURVEILLANCE
Training to ensure valid and reliable
surveillance data
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
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
Surveillance is:
• Policing!
• A survey
– Research
– Audit
HPS’s 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
Today’s climate and demands!
• Public awareness!
• Quality is at the heart
of everyone’s agenda
– Clinical Governance
– Clinical Standards
– Accountability
Reviews
– Performance
Assessment
Framework
HAI - Extent of the problem
• 100, 000 patients
affected per year
• 5000 deaths per
year
The Cost of HAI
AIM
Scottish Surveillance of Healthcare
Associated Infection Programme
• To promote accurate
completion of surgical site
infection surveillance forms
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
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)
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
Introduction to Surveillance
• Surveillance is a multidisciplinary
activity and local ownership is crucial
• National surveillance should be a byproduct of local surveillance
• Local feedback is essential
HAI
Proportion of
all HAI
(%)
Proportion of
extra bed
days(%)
Proportion of
extra cost
(%)
Proportion
preventable?
(%)
UTI
45
11
13
38
SSI
29
57
42
35
Pneumonia
19
24
39
Sur 27; Med13
Bloodstream
2
4
3
35
Other
6
4
3
N/A
Source: Haley 1995 and 1985
HAI
SWI
Cost (£pp)
3246
•in-patient only
Source: Plowman et al. Socio-Economic Burden of HAI
Nat Burden*(£M)
62.37
Background to SSI surveillance – What is the problem?
• Specific operation
categories known to have • Surveillance can result in a
reduced infection rates but is
unacceptably high infection
unlikely to be the only factor:
rates
– ICTs
• Many factors have been
– Commitment of all staff
recognised that influence
– Education on risk
the occurrence of SSI
factors/evidence based
– Pre operative
practice
– Intra operative
– Adequate staffing, resources,
equipment
– Post operative
– Is there a Hawthorne effect?
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
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…………
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
PATIENT PATHWAYS FOR SSI SURVEILLANCE TO POST
OP DAY 30
Admission
Death
Operation
Post Operative
In-patient
Discharge
Transfer
Death
Re-operation
In-patient
to day 30
Post Discharge
Surveillance
Re-admission
PDS to day 30
In-patient end of Surveillance
End of Surveillance
Decide on
operation
categories for
surveillance
Ensure key
personnel are
prepared and all
systems are in
place to
commence the
surveillance
Pilot and launch the
programme
Identify
multidisciplinary
personnel to be
involved in the local
surveillance team
Hold training
sessions for key
personnel to
include SSI
definitions and
data management*
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
*The SSHAIP team at HPS should be
involved at these stages
Project officer
administrates the
surveillance
All forms are
uniquely identified
and originate in
theatre
Surgeon
completes
questions in
theatre
Anaesthetist
completes
questions in
theatre
Theatre nurses
complete questions
on the form
Form is
transferred to
ward with
patient
Ward nurses
complete
questions
IC Dept
provides
local
feedback
Project officer
manages the data
and transfers this to
HPS
ICN contacted
when SSI
present and
completes
questions
Ward clerk returns
forms to the project
officer (Infection
Control department)
when the patient is
discharged
Pre
Pre admit
admit nurse
nurse
places
stored
places stored forms
forms
supplied
by
supplied bycocoordinator
(ICSN
ordinator (ICSN
checks
checks on
on aa weekly
weekly
basis)
basis) in
in all
all patient
patient
notes
notes and
and completes
completes
demographics
demographics
Ward
Ward staff
staff complete
complete
relevant
details
relevant details on
on
the
form
during
inthe form during inpatient
patient stay,
stay,
prompted
prompted by
by
integrated
integrated care
care
pathway
pathway
Surgical
Surgical site
site
inspection
carried
inspection carried
out
out ifif infection
infection
suspected
suspected
NB
NB Forms
Forms are
are pulled
pulled
from
from store
store ifif patient
patient re
re
presents
presents in
in hospital
hospital with
with
surgical
site
infection
surgical site infection
following
following discharge
discharge
Form
Form goes
goes with
with
patient
patient notes
notes to
to
ward
area
ward area
Ward
Ward clerkess
clerkess
completes
completes follow
followup
up
date
on
form
on
date on form on
patient
patient discharge
discharge
and
and sends
sends for
for ms
ms to
to
arthoplasty
arthoplastynurse
nurse
practitioner
practitioner (ANS)
(ANS)
Data
Data sent
sent to
to ICSN
ICSN
and
quality
checks,
and quality checks,
including
including
denominators,
denominators,
performed
performed before
before
feedback
feedback given
given to
to
MDT
monthly
MDT monthly
The
The form
form goes
goes
with
the
patient
with the patient
notes
notes into
into theatre
theatre
All
All operative
operative
details
details completed
completed
by
anaesthetist,
by anaesthetist,
and
and surgeon
surgeon or
or
theatre
theatre nurse
nurse
where
where relevant
relevant
Forms
Forms stored
stored by
by
ANS
and
ANS and
completed
completed as
as
necessary
necessaryat
at
follow
up
review
follow up review
Forms
Forms sent
sent to
to
Audit
Dept
for
Audit Dept for
scanning
scanning and
and
collation
collation
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
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
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
Pan Celtic
Collaboration
IPSE
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 1996;22:457-
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
AIM
Scottish Surveillance of Healthcare
Associated Infection Programme
• To promote accurate
completion of surgical site
infection surveillance forms
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
Definitions of SSI
Superficial SSI (Incisional)
• A superficial SSI must meet the following criterion:
1. Infection occurs within 30 days after the operative procedure
2. And involves only skin and subcutaneous tissue of the incision
3. 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.)
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)
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
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 (>38oC) 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
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.
Definitions of SSI
Organ/Space SSI
•
An organ/space 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 infection involves any part of the body,
excluding the skin incision, fascia, or muscle
layers that is opened or manipulated during the
operative procedure
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
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
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
Extra criteria for organ/ space infection
• Vascular:
– Organisms not isolated from blood/
blood culture not done
• Abdominal
Hysterectomy/
• Orthopaedic:
C.Section:
– Limitation of motion
– Nausea
– Evidence of effusion
– Dysuria
– Organisms and WBC seen on gram stain
– Vomiting
of joint fluid
– Organisms seen
– Positive antigen test on blood, urine or
on gram stain
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)
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
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
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
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.
Wound Classes
• Clean
• Clean contaminated
• Contaminated
• Dirty or infected
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 patient’s records.
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.
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.
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.
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.
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
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)
Form completion – general points
X
• 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 2
• An empty box does not imply anything!
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)
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.
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
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.