A rlene Potts, MPH, BA Population Health/Health Care Quality Assessment/HAI Program NJDOH

1. Preparing Licensed One-Room Centers for HAI Reporting Surgery Center Coalition October 4, 2018 Arlene Potts, MPH, BAPopulation Health/Health Care Quality Assessment/HAI ProgramNJDOH

2. ¾ surgeries performed in outpatient settings

3. Concerns • No good data on infection rates • No familiarity with 2017 CDC Guidelines for the Prevention of Surgical Site Infections. • No formal/structured infection prevention program • No guidelines for surveillance procedures • Center will need an on-site person with Infection Prevention training or contracting with an IP consultant.

4. N.J.A.C. Title 8, Chapter 43A • Regulation requiring licensed ASCs to report specific surgical procedures into the CDC web-based program, the National Healthcare Safety Network (NHSN) • Reporting began January, 2012. • Reportable procedures selected by the Quality Improvement Advisory Committee (QIAC) of the New Jersey Department of Health include: • Breasts (BRST) • Knees (KPRO) • Spines (LAM)

5. One-Room Reporting To Be Determined QIAC will decide what surgical procedures will be reportable as well as the method of reporting and when reporting will begin. • Reportable procedures will be based on volume and risk. • CDC’s “National Healthcare Safety Network (NHSN)” as a reporting method is under review. • Timeline for reporting under review.

6. Preparing for the Reporting Process Develop an active infection prevention program that includes: • CDC definitions for surgical site infections • implementation of evidenced-based guidelines for the prevention of surgical site infections • a surveillance system to capture surgical site infections

7. Resources for Developing an Infection Prevention Program “Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care” highlights existing CDC and HICPAC* recommendations and provide “key recommendations” *Healthcare Infection Prevention Practices Advisory Committee http://www.cdc.gov/HAI/pdfs/guidelines/standards-of-ambulatory-care-7-2011.pdf

8. Resources for Developing an Infection Prevention Program • Center for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. June 21, 2017;152(8): 784-791 • Bratzler DW, et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery: ASHP Therapeutic Guidelines, Amer J of Health Syst Pharm, 2013; 70: 195-283 • Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 360:491-9. (2009)

9. 2017 HICPAC-CDC Guideline for Prevention of Surgical Site Infections Guidelines are ranked. • Category 1A: Strong recommendation supported by high to moderate-quality evidence suggesting net clinical benefits or harms. • Category 1B: Strong recommendations supported by low- quality evidence suggesting net clinical benefits or harms or an accepted practice (e.g., aseptic technique) supported by low to very low quality evidence. • Category 1C: Weak recommendation supported by any quality evidence suggesting a trade-off between clinical benefits and harms.

10. 2017 HICPAC*-CDC Guideline for Prevention of Surgical Site Infections • Category II: Weak recommendation supported by any quality evidence suggesting trade-off between clinical benefits and harms. • No recommendation/unresolved issue: An issue for which there is low to very low quality evidence with uncertain trade-offs between the benefits and harms or no published evidence on outcomes deemed critical to weighing the risks and benefits of a given intervention (e.g., soaking a prosthetic device in an antimicrobial solution before implantation to prevent an SSI). HICPAC – Healthcare Infection Control Practices Advisory Committee

11. Sources of Data - Surveillance Ongoing, systematic collection, analysis, interpretation and dissemination of data regarding a health-related event to reduce morbidity and mortality and to improve health. Surveillance of both process measures and the outcomes to which the processes are linked are important for evaluating the effectiveness of infection prevention efforts. APIC, 2013, page 24

12. Collecting Data on Outcomes and Practices OUTCOMES • Develop a surveillance system to maximize capture of infections. • Establish a connection with acute care facilities in your catchment area. • Provide a simple process for surgeon feedback. PRACTICES • Monitor/audit compliance with best practices to ensure competency.

13. Surveillance on Outcomes Patient call back Physician survey • 6 weeks after last day of month for 30 day surveillance • 14 weeks after the last day of month for 90 day surveillance of deep or organ/space infections - breast, KPRO • Surgeon must notify appropriate person as soon as an infection is identified: • In order to investigate possible prevention methods. • in order to facilitate compliance with Patient Safety Reporting System (PSRS) reporting if criteria met.

14. Example of a form to share with surgeon practices to facilitate reporting. Add section for culture and sensitivity report. request cx date and site from testing facility. Also any other testing done and results.

15. NHSN Definitions • Definitions can be used universally, not just those reporting into CDC/NHSN. • Purpose: to coordinate CDC/NSHN definitions with other surgical professions. • Data collected by CDC/NHSN in 2015 will provide the baseline for 2016 Standardized Infection Ratio (SIR) calculations to provide a benchmark for comparisons to be used by acute care facilities. • There are no current benchmarks for ambulatory surgery centers. • Published infection rates are risk-stratified.

16. Risk - Wound Classification Low risk for infection I. Clean • uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. • operative incisional wounds following nonpenetrating (blunt) trauma – if criteria met II. Clean-Contaminated • operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination

17. Risk - Wound Classification Class III or IV with increased risk = 1 risk point. III. Contaminated • open, fresh, accidental wounds • major breaks in sterile technique • incisions in which acute, non-purulent inflammation is encountered IV. Dirty/Infected • old traumatic wounds with retained devitalized tissue • existing clinical infection

18. Risk – American Society of Anesthesiologists (ASA) Score ASA score of 3 or higher = 1 risk point. 1. a normally healthy patient 2. a patient with mild systemic disease 3. A patient with severe systemic disease 4. A patient with severe systemic disease that is a constant threat to life 5. a moribund patient who is not expected to survive without the operation.

19. Risk - Duration of Procedure A duration beyond the published CDC/NHSN “T” time =1 risk point. • Procedure/Surgery Start Time (PST): Time when the procedure is begun (e.g., incision for a surgical procedure) • Procedure/Surgery Finish (PF): Time when all instrument and sponge counts are completed and verified as correct, all postoperative radiologic studies to be done in the OR are completed, all dressings and drains are secured, and the physicians/surgeons have completed all procedure-related activities on the patient • With multiple incisions or bilateral procedures, list the times for each incision if possible. If not, take the entire time and divide by number of incisions

20. Other Risk Factors Diabetes = 1 risk point • The NHSN SSI surveillance definition of diabetes indicates that the patient has a diagnosis of diabetes requiring management with insulin or a non-insulin anti-diabetic agent. acceptable for use to answer YES to the diabetes field question. • The NHSN definition excludes patients with no diagnosis of diabetes. The definition excludes patients who receive insulin for perioperative control of hyperglycemia but have no diagnosis of diabetes. • Hgt & Wgt: A BMI 30 or > = 1 risk point – BMI to be considered with pre-op antibiotic dosage

21. CDC Definitions - Incision Site Primary incision • main incision Secondary incision • e.g., a tissue harvest site (transverse rectus abdominis myocutaneousTRAM flap) in a BRST If the secondary incision becomes infected, report as either superficial or deep as appropriate.

22. CDC Definitions - Incisional Closure Type Primary Closure* • closure of all tissue levels during original surgery, regardless of presence of wires, wicks, drains, or other devices or objects extruding from the incision. Non-primary Closure • includes surgeries in which the superficial layers are left completely open during the original surgery. Information should be available in the operative report. * NHSN has closely adopted the American College of Surgeons, NSPQIP definition of primary closure.

23. CDC Definitions - Infection Type • Superficial incisional infection (SIP or SIS) • Deep incisional infections (DIP or DIS)* • Organ/space infection* • E.g., Breast abscess or mastitis; eye, other than conjunctivitis; spinal abscess, other than meningitis; disc space, and joint or bursa • For complete list of infection criteria, go to: http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf *MD diagnosis removed from deep and organ/space infections for the purpose of NHSN reporting.

24. CDC Definitions - Infection Type • Surveillance Definitions for Specific Types of Infections, CDC/NHSN Chapter 17, Jan 2015 Diagnosis of Infection versus Surveillance Definitions • CDC/NHSN surveillance definitions – population based to identify trends (objective) • diagnosis – made by a physician for the purpose of treating one specific individual (subjective)

25. Calculating Surgical Site Infection Rates Surgical site infections are reported as percentages. Calculate a surgical site infection (SSI) rate as follows: • SSI rate= # surgical site infections in a specific time period divided be number of surgical procedures within the same time period multiplied by a 100 to give a percent. • Denominator must reflect population at risk for specific infection. • Example: • SSI rate = 5 surgical site infections in October/ 230 surgical procedures performed in October x 100 • SSI rate = 5/230*100 • SSI rate = 2.2%

26. Measuring Compliance with Processes Measure compliance with processes/practices (tasks) that occurred within a specified time frame. If practice is good, a good outcome should follow. # times process performed correctly / # opportunities to perform correctly x K examples: hand hygiene processing scopes starting an IV Inserting an indwelling urinary catheter

27. Measuring Compliance with Processes hand hygiene compliance monitored for one hour 15 opportunities for appropriate hand hygiene practices are noted but hand hygiene only performed 10 times rate = 10 /15 x 100 rate = 66.7 per 100 opportunities or 67% compliance with hand hygiene practices.

28. You observe five HCW completing a process, using a checklist of 10 steps appropriate to the procedure. Ex. IV insertion # steps • three observations – all 10 steps followed 10 x 3 = 30 • on one insertion, only 8 steps followed 8 x 1 = 8 • one insertion, 9 steps followed 9 x 1 = 9 • total number of steps followed 47 • total number of steps required 10 x 5 = 50 • compliance rate • 47 steps followed/50 steps required x 100 = 94% compliance rate with appropriate procedure steps

29. Preventing Surgical Site Infections Evidenced-based guidelines for the prevention of surgical site infections include: • Hand hygiene • Antibiotic regimen • Hair removal • Glucose control • Normothermia • Safe Surgery checklists • Environmental and equipment cleaning and processing

30. Prevention Strategies • Pre-op showers • Antibiotic Stewardship • correct drug – correct dose (BMI) – correct duration (pre-op; within 1 hour of incision vancomycin & fluoroquinolones* - 2 hours and intra-op re-dosing if indicated by half-life of antibiotic. • Skin prep - application and “wet” contact time • Decolonization – MRSA (?) *Bratzler DW, et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery: ASHP Therapeutic Guidelines, Amer J of Health Syst Pharm, 2013; 70: 195-283

31. Prevention Strategies • no infection at a remote site • attire (skull caps) • jewelry • artificial/long natural nails • traffic control • equipment/environment

32. Checklist reduced the rate of postoperative complications and death by more than one-third! World Health Org -Safesurgery2015.Org

33. Arlene Potts, MPH, BA (609) 341-5554 arlene.potts@doh.nj.gov