SURGICAL SITE INFECTIONS SURVEILLANCE & PREVENTION

1. SURGICAL SITE INFECTIONS SURVEILLANCE & PREVENTION

2. Objectives • List evidence based prevention strategies • Define Surgical Site Infections based on NHSN definitions • Describe surveillance tips

3. Facts According to 2018 Patient Safety Movement Foundation: • There are approximately 300,000 SSIs annually. • 17% of all HAIs, second only to UTIs. • SSIs occur in 2%-5% of patients undergoing inpatient surgery • The SSI mortality rate is 3% with a 2-11% times higher risk of death versus other infections. • 75% of deaths among patients with SSI are directly attributable to the SSI. • Long term disabilities can result from SSIs, resulting in life-altering disabilities and associated financial burdens.

4. So what’s reportable in Texas?

6. Prevention of SSI Pre-operative Skin cleansing with CHG and educate patients on how to apply/bathe/shower & shampoo prior to surgery Pre-operative screening for patients at risk for SSI. Nasal screening for Staphylococcus aureus in patients undergoing cardiac and elective orthopedic surgery Decolonize protocol for carriers with intranasal meds.

7. Educate patients & families on SSI prevention. Stop smoking – affects wound healing Proper nutrition Diabetes needs to be controlled Identify skin irritations and hypersensitivity & any new skin abrasions Post-op wound healing techniques used Proper Hand Hygiene Proper hair removal (NO SHAVING or RAZORS, clipping only those areas needed).

8. Appropriate timing, selection and duration of prophylactic antibiotics • Maintain normothermia with forced air blankets, pre-op, during surgery and in PACU. • Use warmed IV fluids for IVs and flushes • Traffic control in the OR • Protect primary closure incisions with sterile dressing for 24-48 hours post-op • Discontinue ABX within 24 hours after surgery unless s/s of infection are present.

9. NHSN Operative Procedure • that is included in the ICD-10-PCS or CPT NHSN operative procedure code mapping AND • takes place during an operation where at least one incision (including laparoscopic approach and cranial Burr holes) is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure AND • takes place in an operating room (OR), defined as a patient care area that met the Facilities Guidelines Institute’s (FGI) or American Institute of Architects’ (AIA) criteria for an operating room when it was constructed or renovated11. This may include an operating room, C-section room, interventional radiology room, or a cardiac catheterization lab.

10. NHSN Inpatient Operative Procedure NHSN Inpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and the date of discharge are different calendar days.

11. NHSN Outpatient Operative Procedure NHSN Outpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and date of discharge are the same calendar day.

13. Primary Closure Primary Closure = closure of the skin level during the original surgery, regardless of the presence of wires, wicks, drains, or other devices or objects extruding through the incision, includes surgeries where the skin is closed by some means. Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery. NOTE: If a procedure has multiple incision/laparoscopic trocar sites and any of the incisions are closed primarily, then the procedure is entered as having been closed primarily. • This change removed the phrase “all tissue levels” from the definition. This definition will be easier to apply and is closer to definitions used by other surgical professional groups.

15. Non- Primary Closure • Skin level is left completely open during the original surgery • Deep tissue layers may be closed by some means (with the skin level left open), or the deep and superficial layers may both be left completely open. • Wounds with non-primary closure may or may not be described as "packed” with gauze or other material, and may or may not be covered with plastic, “wound vacs,” or other synthetic devices or materials. • For example: a laparotomy in which the incision was closed to the level of the deep tissue layers, sometimes called “fascial layers” or “deep fascia,” but the skin level was left open. • For example: an “open abdomen” case in which the abdomen is left completely open after the surgery.

18. Case 1 • A patient is admitted with a ruptured diverticulum and a COLO procedure is performed in the inpatient OR. • Case is entered as a wound class 3 • Specimen is obtained in the OR which later returns (+) for E. coli • The skin incision was closed at 4 locations with staples with gauze packing in between.

19. Is this procedure primarily closed? 1. Yes 2. No

20. Is this procedure primarily closed? 1. Yes 2. No

21. Case 1 -Rationale The skin is closed at some points along the skin incision. Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery.

22. If you are following COLO in your monthly reporting plan should this case be entered into your denominator data? 1.Yes 2.No

23. If you are following COLO in your monthly reporting plan should this case be entered into your denominator data? 1.Yes 2.No

24. Surveillance • Surveillance of SSIs with feedback of appropriate data to surgeons has been shown to be an important component of strategies to reduce SSI risk. • A successful surveillance program includes the use of epidemiologically sound infection definitions and effective surveillance methods • stratification of SSI rates according to risk factors associated with SSI development • data feedback A new CDC and Healthcare Infection Control Practices Advisory Committee guideline for the Prevention of Surgical Site Infection has been published in 2017 and has replaced the previous Guideline for Prevention of Surgical Site Infection, 1999

25. CDC Definitions • NHSN manual from Jan 2018 • http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf • 3 Types • Superficial Incisional SSI • Deep Incisional SSI • Organ/ Organ Space

26. Sources of Data for Finding SSI Microbiology reports Infection control rounds on nursing units Pharmacy reports for antimicrobial use Operating room report of surgeries Use post-discharge surveillance methods for SSI Electronic Surveillance Programs ER Diagnosis List Case Managers IPs in your community!

27. Important Information! • Please note that key terms that have been defined in other NHSN trainings (e.g. CLABSI, CAUTI) including Infection Window Period, Present on Admission (POA), Healthcare-associated Infection (HAI), and Repeat Infection Timeframe (RIT) DO NOT apply to SSI!

28. Date of Event • Date of event (DOE): For an SSI the date of event is the date when the first element used to meet the SSI infection criterion occurs for the first time during the surveillance period. • The date of event must fall within the SSI surveillance period to meet SSI criteria.

29. DOE for SSIs that progress to a deeper level during surveillance period SSIs are always reported at the deepest level that they occur within the surveillance period. If during the surveillance period a patient’s initial SSI meets criteria for a deeper level, then the date of event should be the date for the deepest level.

31. Example For example: • Day 1 –COLO procedure • Day 6 –DOE for meeting a superficial incisional SSI • Day 25 –DOE for the meeting an organ space IAB SSI • Only report one SSI with the DOE for the organ space IAB

32. Pathogen Assignment • The Pathogen Assignment Guidance found in Chapter 2 “Identifying HAIs” is based on Repeat Infection Timeframes (RIT) which is not used with SSIs • SSI are procedure based and have long surveillance periods (30 to 90 days) • SSIs can progress to a deeper level during a surveillance period and a new pathogen can be found. • Pathogen Assignment for SSI has not changed.

33. BSI Secondary to an SSI Secondary BSI Attribution Period: The secondary BSI attribution period for SSI is a 17-day period that includes the date of SSI event, 3 days prior & 13 days after. For other HAIs the Secondary BSI attribution period is determined by using: • Infection Window Period • Repeat Infection Timeframe. These two definitions do not apply to SSI.

35. Any blood culture that occurs during the SSI Secondary BSI attribution period will be assessed using Appendix B in the BSI protocol to determine if the blood meets Secondary BSI criteria. • If a (+) blood culture occurs after the SSI secondary BSI attribution period it should be fully evaluated to see if at that time it is meeting criteria to be secondary to an ongoing SSI.

36. PATOS- Infection present at time of surgery • Infection present at time of surgery (PATOS) denotes there is evidence of an infection/abscess at the time of the start of or during the index surgical procedure (present pre-operatively). • This field is a required field and it is found on the SSI event form not on the denominator for procedure form.

37. Only select PATOS = YES if it applies to the depth of SSI that is being attributed to the procedure • IF: • a patient had evidence of an intra-abdominal infection at the time of surgery and then later returns with an organ space SSI the PATOS field would be selected as a YES. • If the patient returned with a superficial or deep incisional SSI the PATOS field would be selected as a NO.

38. The patient does not have to meet the NHSN definition of an SSI at the time of the primary procedure but there must be notation that there is evidence of infection or abscess present at the time of surgery.

39. All of the SSI SIR reports that use the new 2015 SSI baseline will exclude SSIs that are reported as present at time of surgery from both the numerator and denominator. • Meaning the PATOS event is excluded in the numerator of the SIR and the procedure from which the event occurred is excluded in the denominator of the SIR.

40. Case 2 • Patient was admitted with an acute abdomen, to OR for XLAP with findings of an abscess due to ruptured appendix and an APPY is performed. • Patient returns 2 weeks later and meets criteria for an organ space IAB SSI.

41. Does this patient meet the criteria for PATOS? • PATOS= NO • PATOS= YES

42. Does this patient meet the criteria for PATOS? • PATOS= NO • PATOS= YES

43. Since this SSI is related to an infection that was PATOS it does not have to be reported to NHSN. • True • False

44. Since this SSI is related to an infection that was PATOS it does not have to be reported to NHSN. • True • False

45. Case 2 -Rationale • The PATOS field would be selected as YES since there was evidence of infection at the time of surgery and the subsequent SSI developed at the same level. • Infections that meet SSI criteria and have the PATOS field as a YES are reported to NHSN.

49. Reporting Instruction -24 Hour Rule (SSI Protocol 9-20) If the wound class has changed, report the higher wound class. If the ASA class has changed, report the higher ASA class. Note: When the patient returns to the OR within 24 hours of the end of the first procedure assign the surgical wound closure technique that applies when the patient leaves the OR from the first operative procedure.

50. Same NHSN operative procedure via separate incisions For operative procedures performed via separate incisions during same trip to operating room (i.e., AMP, BRST, CEA, FUSN, FX, HER, HPRO, KPRO, LAM, NEPH, OVRY, PVBY, REFUSN), separate Denominator Procedure forms are completed. To document the duration of the procedures, indicate the procedure/surgery start time to procedure/surgery finish time for each procedure separately OR alternatively, take the total time for the procedures and split it evenly between procedures. SSI Chapter : Denominator Data Reporting Instructions