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Addressing some NHSN Definitions. Recording multiple proceduresRecording denominatorsAssigning infectionsDetermining duration cut point Addressing issue reporting for state required measures and those recorded for the hospital's own useClosure of the incisionSchedule for next HAI report. Mult
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1. NHSN SSI Clarifications Janet Sullivan, Oregon SW Washington APIC
Jeanne Negley, Oregon Health Policy & Research
2. Addressing some NHSN Definitions Recording multiple procedures
Recording denominators
Assigning infections
Determining duration cut point
Addressing issue reporting for state required measures and those recorded for the hospital’s own use
Closure of the incision
Schedule for next HAI report
We will be addressing some recent discussion items regarding NHSN definitions. The list includes: . . . We will also be discussing the schedule for the next HAI report.
We will be addressing some recent discussion items regarding NHSN definitions. The list includes: . . . We will also be discussing the schedule for the next HAI report.
3. Multiple Procedures through the same incision Two characters:
Sally State: only reports state required measures
Robert Reportall: reports state measures and additional procedures
Assumption: all procedures presented below are NHSN procedures (defined by ICD-9 codes in Table 1 of Chapter 9, NHSN SSI protocol).
Scenario: inpatient small bowel, colon, and rectal NHSN procedure performed through a single incision during a single trip to the OR.
To discuss recording multiple procedures (including multiple procedures through the same incision), I have created two characters, Sally State (who reports state-only measures) and Robert Reportall (who reports state measures and additional measures for his facility’s own use).
Assume that these are NHSN procedures. Refer to Table 1 of Ch. 9 NHSN protocol. Also refer to spreadsheets with ICD-9 codes recently distributed by OHPR.
Present scenario for definition application.
To discuss recording multiple procedures (including multiple procedures through the same incision), I have created two characters, Sally State (who reports state-only measures) and Robert Reportall (who reports state measures and additional measures for his facility’s own use).
Assume that these are NHSN procedures. Refer to Table 1 of Ch. 9 NHSN protocol. Also refer to spreadsheets with ICD-9 codes recently distributed by OHPR.
Present scenario for definition application.
4. Multiple Procedures through the same incision Question 1: What procedures (denominators) do I report in NHSN?
Sally State: COLO
Robert Reportall: COLO, REC, SB
Question 2: What if an infection is identified?
Sally State:
When multiple procedures through the same incision, first attempt to determine which procedure is responsible for SSI.
If it is clear the COLO procedure is responsible, report it to NHSN. (Infection will be reported to state.)
If it is unclear (you are not able to determine) which procedure is responsible for the SSI, assign it to the highest surgical code in the priority table.
If the infection is assigned to REC or SB, do not report the infection to NHSN.
Option: use NHSN optional field to record that infection was assigned to REC or Priority List used to assign to SB. Walk through example, explaining differences between “state” and “reportall” reporting, including procedures and infections. Need examples of when an infection that results from multiple procedures through one incision can be assigned to a specific procedure.
Walk through example, explaining differences between “state” and “reportall” reporting, including procedures and infections. Need examples of when an infection that results from multiple procedures through one incision can be assigned to a specific procedure.
5. Multiple Procedures through the same incision Question 2: What if an infection is identified?
Robert Reportall:
When multiple procedures through the same incision, first attempt to determine which procedure is responsible for SSI.
If it is clear the COLO procedure is responsible, report it to NHSN. (Infection will be reported to state.)
If it is clear REC or SB procedure is responsible, report to NHSN. (Infection not reported to state.)
If it is unclear (you are not able to determine) which procedure is responsible for the SSI, assign it to the highest surgical code in the priority table.
Option: use NHSN optional field to record that infection was assigned to REC or Priority List used to assign to SB. Walk through example, explaining differences between “state” and “reportall” reporting, including procedures and infections. Need examples of when an infection that results from multiple procedures through one incision can be assigned to a specific procedure.
Walk through example, explaining differences between “state” and “reportall” reporting, including procedures and infections. Need examples of when an infection that results from multiple procedures through one incision can be assigned to a specific procedure.
6. The NHSN “Priorities List” Table 3 of Chapter 9 of NHSN Protocol, Procedure Associated Events SSI Refer to priorities list. State where providers can find the original list.
Refer to priorities list. State where providers can find the original list.
7. Multiple Procedures through the same incision Question 3: If we record multiple procedures doesn’t that inflate the colon procedure, since with the Priority Lists many SSIs would be attributed to the small bowel?
It does increase the probability that an infection will be attributed to the small bowel (i.e., the more infections attributed to small bowel, the higher it stays on the Priorities Lists). NHSN does periodically review the list with surgeons, just to make sure the priorities are appropriate, but we are aware of this issue.
Question 4: If we are recording multiple procedures through one incision, how do we record duration cut point for the multiple procedures?
The duration cut point represents the actual amount of time that the surgical site (which is basically the same for both) is open and at risk for infection. Therefore, if you conduct a COLO, RB, and SB procedure for 3 hr and 10 minutes, you would record each procedure for 3 hr and 10 minutes
Read through additional questions.
CBGB is really the “exception only” example—for recording of procedures and duration cut time.
Duration cut time is from incision to closure. It is not anesthesia time nor OR time.
Notes on HPRO:
TP (Total Primary)
PP (Partial Primary)
TR (Total Revision)
PR (Partial Revision)
Read through additional questions.
CBGB is really the “exception only” example—for recording of procedures and duration cut time.
Duration cut time is from incision to closure. It is not anesthesia time nor OR time.
Notes on HPRO:
TP (Total Primary)
PP (Partial Primary)
TR (Total Revision)
PR (Partial Revision)
8. Multiple Procedures through the same incision Question 5: How is recording of duration cut point different for CBGB and KPRO bilateral knees?
For bilateral procedures (e.g., KPRO), two separate Denominator for Procedure are completed. To document the duration of the procedure, indicate the incision time to closure time for each procedure separately, or alternatively, take the total time for both procedures and split it evenly between the two.
For CBGB, record the time from skin incision to primary closure. (see pages 9-12 to 9-13 of Chapter 9 of the NHSN Manual).
Read through additional questions.
CBGB is really the “exception only” example—for recording of procedures and duration cut time.
Duration cut time is from incision to closure. It is not anesthesia time nor OR time.
Read through additional questions.
CBGB is really the “exception only” example—for recording of procedures and duration cut time.
Duration cut time is from incision to closure. It is not anesthesia time nor OR time.
9. Closure of the Incision An NHSN Operative Procedure is a procedure
1) this is performed on a patient who is an NHSN inpatient or an NHSN outpatient; and 2) takes place during an operation (defined as a single trip to the operating room (OR) where a surgeon makes at least one incision through the skin or mucous membrane; including laparoscopic approach and closes the incision before the patient leaves the OR; and
3) that is included in Table 1.
On page 9-7 of Chapter 9, here is the definition for an NHSN operative procedure. We will look more closely at the “closure of incision” definition.
On page 9-7 of Chapter 9, here is the definition for an NHSN operative procedure. We will look more closely at the “closure of incision” definition.
10. Further Clarification on “closing the incision” If the incision is not entirely closed at the procedure’s end (e.g., if wires or tubes extrude though the incision) then the procedure does not meet the criteria of an NSHN operative procedure. Some examples follow.
If a drain is placed within the surgical incision, this procedure WILL NOT be counted as an NHSN procedure. If the surgical drain is placed via stab wound and is not enclosed in the surgical incision, this procedure will meet criteria as meeting an NHSN procedure.
It is standard procedure to place drains in stab wounds.
So, I wrote to NHSN regarding a definition of “closure of the incision,” and here is their response with some examples.
So, I wrote to NHSN regarding a definition of “closure of the incision,” and here is their response with some examples.
11. Further Clarification on “closing the incision” (part 2) MORE EXAMPLES
The insertion of pacer wires in the incision for open heart surgery can also affect whether a procedure meets the criteria as an NHSN procedure. If your facility inserts pacer wires through the mediastinal incision after open heart surgery, it would not allow your surgery to be included as surgical procedures within NHSN. If the pacer wires are brought through another skin site, not from within the surgical incision, then it can be included as an NHSN procedure.
It is standard procedure to have pacer wires extrude through alternative skin sites, NOT in the surgical incision.
We understand that some facilities may have a large volume of colon surgeries, and it may not be possible for IPs to check every surgery report to determine if the surgery was closed. In these circumstances, we recommend that the IP review the surgery reports for all surgeries with Type 4 wound classes (i.e., wounds that are classified as dirty/infected).
So, I wrote to NHSN regarding a definition of “closure of the incision,” and here is their response with some examples.
So, I wrote to NHSN regarding a definition of “closure of the incision,” and here is their response with some examples.
12. Will the incision be closed? It needs to be understood that the majority of procedures have closed incisions. Here’s a picture of closing a hip replacement surgery with a drain extruding from a stab wound. This is an NHSN procedure. You need to enter a denominator for this procedure and a numerator (if an infection occurs).
It needs to be understood that the majority of procedures have closed incisions. Here’s a picture of closing a hip replacement surgery with a drain extruding from a stab wound. This is an NHSN procedure. You need to enter a denominator for this procedure and a numerator (if an infection occurs).
13. Will the incision be closed? Here’s another picture of an incision for hip surgery that will meet the definition of a closed incision. In this picture, the drain is inserted through the primary incision and exits through the stab wound. Upon completion of the surgery, the primary incision will NOT be sutured around the drain line and the drain will extrude from the stab wound. Therefore, this will be a closed incision and will be reported as an NHSN procedure.
Here’s another picture of an incision for hip surgery that will meet the definition of a closed incision. In this picture, the drain is inserted through the primary incision and exits through the stab wound. Upon completion of the surgery, the primary incision will NOT be sutured around the drain line and the drain will extrude from the stab wound. Therefore, this will be a closed incision and will be reported as an NHSN procedure.
14. Conclusions: closure of incision Drains are routinely placed in stab wound adjacent to surgical incision.
Pacer wires for CBGB routinely extrude from adjacent skin sites (not surgical incision).
No need to check surgery reports for all surgeries.
Recommend checking surgery reports for wound class 4 (dirty/infected).
15. Schedule for Next HAI Report February 14, 2011, OHPR will pull data set for next report.
All data through December 31, 2010.
NHSN Annual Survey.
Any corrections you have to your data set to 2009 and 2010.
CLABSI validation updates.
Additional findings from your data review efforts.
Communication appreciated.
Input on additional training needs?
Wound classification
16. Questions? Jeanne Negley
Office for Oregon Health Policy & Research
503-373-1793
Jeanne.Negley@state.or.us
http://www.oregon.gov/OHPPR/Healthcare_Acquired_infections.shtml
17. Adding an Optional Field to Procedure Form Add a custom field to your NHSN procedure form.
Facility?Customize Forms?Form Type? CDC-Defined—PS—Patient Safety, Form Type: COLO.
In the section Alphanumeric/Label 1, you can input “infection note.” “Save.”
Save. Go into COLO procedure form, you will see field where you can type in a 16-character note.
18. Adding an Optional Field to Procedure Form--example