All About Surgical Site Infections

1
All About Surgical Site Infections

• Lessons learned from the SSI surveillance pilot,
  SSI mini grant program, and the data presentation
  collaborative

Andrea Alvarez, MPH HAI Program
Coordinator Virginia Department of
Health Jacqueline P. Butler, CIC Dir, Infection
Prevention Control Sentara Healthcare November
10, 2011
2
SSI Surveillance Pilot Purpose

• Public reporting expectations increasing
• Multiple factors to consider when choosing a SSI
  for public reporting
• Troubleshoot issues with surveillance definitions
• Quantify time requirements for surveillance
• Gather lessons to help prepare other facilities
  for reporting

3
Perceived Pilot Benefits

• Increase awareness of SSIs
• More focus on prevention practices, monitoring
  associated outcomes, physician awareness of
  surveillance definitions
• High profile, high risk, high priority procedures
• Providing standardized benchmark data
• Prepare for future reporting requirements
• Gain more experience in NHSN data entry
• Increase upload or electronic capabilities
• Quantify the time associated with procedure
  surveillance
• Identify demands for reporting to facilitate
  processes to reduce burden
• Feed data back to those who can make a difference

4
SSI Pilot Methods Selecting Hospitals and
Procedures

• Coronary artery bypass graft (CABG), hip
  replacement (HPRO), knee replacement (KPRO)
  surgeries
• Consumer interest, experiences of other states,
  morbidity
• Surgical Care Improvement Project (SCIP)
  antibiotic measures
• Align process measures with outcome measures
• Pilot feasibility of publicly reporting
  procedure-specific SCIP data
• 18 hospitals
• Randomly selected by bedsize category and number
  of procedures performed
• Voluntary participation
• Incentives educational stipend (conferences,
  journal subscriptions, etc.)

5
Pre-Survey

• 18/18 facilities responded (100)
• Well prepared
• 100 enrolled in NHSN and used NHSN definitions
• 94 calculated SSI rates
• Relatively well prepared
• 2/3 currently collected patient-level information
• Prevention efforts already underway
• SSI surveillance deemed high or medium priority
• Not well prepared
• One facility was currently entering data into
  NHSN for the pilot procedure
• No facilities currently uploaded denominator data
• Limited communication between surgical and IP
  databases
• 50 perceived surveillance to be somewhat or very
  difficult

6
Methods - Training

• Partnership with APIC-VA for training and
  distribution of incentives
• One-day training (June 9, 2010)
• Case studies prepared by APIC-VA
• Monthly conference calls
• Surveillance QA
• Data import discussions
• Feedback of data

7
Some Surveillance Pointers

• Definitions Ensure the latest version of the
  definitions are being used
• Deep incisional vs. organ space
• Increases consistency and standardization
• SSIs are attributed to the date of the operation
• For SSIs identified on readmission, on the event
  form use the date of admission and discharge for
  the surgery visit
• All surgical procedures must be entered into NHSN
• Not only procedures with an event (like CLABSIs)
• Only need to report the required sensitivities
• To report a pathogen that is not on the list of
  common pathogens, right-click in pathogen field

8
NHSN Clarifications

• Deep incisional vs. organ space
• If an incision is opened, the infection is
  counted as deep incisional no matter where it
  travels
• A knee that has never been operated on before is
  always a primary regardless of whether it is a
  total or partial surgery
• Transplant
• Includes internal staples
• Does not include a blood transfusion
• SSI standardized infection ratios (SIRs) only
  include primary sites

9
Methods Data Reporting

• Monthly entry of procedures and infection events
  into NHSN
• Procedures from July Dec 2010 with 6 months of
  post-discharge surveillance
• Quarterly submission of SCIP data
• Jan-June 2010 (baseline), July-Dec 2010 (pilot)
• Time and effort
• Time spent on surveillance
• Number of staff involved with surveillance

10
Electronic Upload Methods ASCII File

• Comma delimited ASCII file (.txt or .csv) created
  by the facility
• Can be generated from different external sources,
  such as infection prevention databases or
  hospital information systems
• Requires assistance of operating room and/or IT
  staff
• Specifications for values, format, and data
  requirements must be followed
• Specifications and instructions available on NHSN
  website
• http//www.cdc.gov/nhsn/PDFs/ImportingProcedureDat
  a_current.pdf

11
Electronic Upload Methods CDA

• Clinical Document Architecture (CDA)
• Health Level 7 (HL7) standards used to provide a
  consistent format framework for electronic
  documents
• Not all vendors have the capacity to create
  documents in this HL7 framework
• Specifications and instructions available on NHSN
  website
• http//www.cdc.gov/nhsn/ CDA_eSurveillance.html
• Examples of vendors with CDA compatibility
• Atlas Development Corporation
• BD Diagnostics (formerly known as AICE or ICPA)
• CareFusion / MedMined from Cardinal Health
• Cerner Corporation
• EpiQuest
• ICNet International Limited
• RL Solutions
• SafetySurveillor by Premier
• Sentri7 by PharmacyOne
• TheraDoc Hospira, Inc.

List compiled by APIC
12
SSI Pilot Time and Effort per Facility
2010
2011
Readmission/post-discharge only
13
SSI Pilot Time and Effort per Person
2010
2011
Readmission/post-discharge only
14
Results SCIP Data

• SCIP 1 Timely receipt of antibiotic prior to
  surgery
• SCIP 2 Receipt of appropriate antibiotic
• SCIP 3 Timely discontinuation of antibiotic
  after surgery

15
Results SSIs Identified

• 2,388 procedures conducted
• 25 SSIs included in SIR calculation
• Secondary infections are not included in SIR
• - All CABG (N5)
• 64 CABG, 24 KPRO, 12 HPRO
• ASA score and duration of procedure highest for
  CABG
• 3 occurred gt 30 days after procedure (all KPRO)
• SIR 0.72
• Interpretation The pilot facilities identified
  28 fewer SSIs than expected based on the
  national experience.
• Not statistically significant

16
Post-Survey

• 14/18 facilities responded (78)
• Facilities more prepared for public reporting
• Staff review SSI definitions more closely
• IT changes
• Many facilities changing or considering changing
  vendors
• Changes to administrations prioritization of
  SSI surveillance (4 facilities)
• No change in IPs perspective of the magnitude of
  the problem of SSIs in their facility

17
Benefits to Participation

• 93 - Helped to prepare for future reporting
  requirements
• 79 - Gained more experience in NHSN data entry
• 57 - Facilitated process needed to meet pilot
  demands and future reporting
• 50 - Demonstrated how much time was associated
  with HAI surveillance to find ways to decrease
  burden on workload
• 43 - Automated upload and/or increased
  electronic capabilities
• 43 - Increased awareness of SSIs

18
Barriers Encountered

• 50 Learning curve
• Data entry
• Importing data
• 43 Time/resource limitations
• Data entry
• Staffing
• 29 No barriers
• 14 Post-discharge surveillance
• 14 Consistency between facilities

19
Electronic Upload to NHSN

• Pre-survey 0 facilities End of pilot 9
  facilities (50!)
• 6 facilities submitted feedback on upload process
• 4 used Clinical Document Architecture (CDA)
  technology
• 3 BD/AICE, 1 unspecified vendor
• Decreases in monthly surveillance effort after
  implementing CDA
• 8 hours to 2 hours
• 8 hours to 1 hour
• Time required to set up import averaged several
  months
• 2 used .CSV file
• Decreased monthly surveillance effort in one
  hospital from 5 hours to 1 hour
• Took 2 months for one hospital to set up its file
  transmission
• 2 hospitals used DICON to help with their
  electronic import
• 4 of these hospitals used Meditech for their
  patient medical records

20
Lessons Learned / Challenges

• Electronic medical record system (EMR) is
  necessary for the electronic upload and any
  movement towards increased use of EMR would be of
  help to the facility
• Helpful to talk to other facilities using the
  same systems and see if they have been able to
  set up a file transfer
• Sometimes easier for facility IT staff to talk to
  each other rather than IP trying to explain to IT
  what is needed
• Importance of monitoring all exported data for
  quality

21
Lessons Learned / Challenges

• Operating room system capability and
  compatibility
• Writing the data dictionaries challenge!
• Concern about changing dictionaries/remapping
  elements if NHSN amends definitions or changes
  required fields
• Team approach required (quality, IT, other
  departments)
• Establish importance of support of the infection
  prevention program on a local level first
• IT support is critical for implementation and to
  address data quality
• Vendor representatives can play a beneficial role

22
PERSPECTIVES FROM THE PARTICIPANTS
23
Experiences of a Large System

• Sentara Healthcare (SH)
• gt23,000 staff, gt100 care giving sites,
  including 10 acute care hospitals with a total
  of 2,349 beds
• Sentara Norfolk General Hospital / Sentara Heart
  Hospital
• Patients receive comprehensive cardiac services -
  from diagnostics to open heart surgery and
  transplants.
• State-of-the-art hospital features all-private
  rooms, including 112 inpatient beds and 45
  pre/post procedural rooms for patients undergoing
  interventional cardiac procedures.
• Houses 5 cardiac operating rooms designed to
  accommodate 2,000 cardiac surgeries a year.

24
Timeline of Sentaras Pilot Period

• Calm down
• Education June 9, 2010
• Define current surveillance process for CABG
• Develop a Team (IT, Contracted Vendor, Cardiac
  Auditors, Leadership, IPC) to research ability
  to electronically export denominator surgical
  data to NHSN
• Contracted Cardiac Vendor building a background
  program to develop a report off the STS Cardiac
  Surgery Database (CSD) for exporting
• Began reporting requirements for pilot project
  (numerator data, denominator data export, SCIP
  measure data, time effort measures) September
  1, 2010 for July 2010 data
• Completion ongoingWhy stop a good process?

25
Sentaras Experiences

• Pit Falls
• Took time to map SH surgical denominator
  components (STS CSD) to NHSN template for export
• Time allotment for cardiac abstractors to review
  surgical patients
• Contracted vendor - Armus
• Experience
• Positive
• Demonstrated SHs ability to address issues of
  mandatory reporting

26
Building in a Collaborative

• Requirement of ARRA funding
• Create a project to be flexible and responsive to
  acute care IPs workload
• Collecting data presentation templates
• Sharing best practices for data feedback
• Monthly conference calls
• Survey given to IPs and unit-specific staff to
  capture the various perceptions of data utility

27
Data Presentation Survey

• Collect baseline of knowledge regarding data
  presentation practices targeted to direct care
  staff
• Sent to IPs, direct care staff in a selected
  unit/area
• 18 facilities (100) 17 IPs and 84 staff
• General statements about use of data to lower HAI
  rates or impact infection prevention compliance
• Types of staff and their perceived awareness of
  HAI data and compliance with infection prevention
  practices
• Outcome and process measures staff want to see
  and are currently provided
• Types of data and whether they are easy to
  understand, useful, and currently presented

28
Data Presentation Survey Results IP and Staff
Perceptions

• Awareness of HAI data promotes dialogue among
  staff and impacts infection prevention compliance
• IPs more likely to think that SSI rates were
  improving (65 vs. 48)
• Most respondents thought unit-specific HAI data
  were valid and reliable, easy to understand,
  timely, and shared at least quarterly

29
Survey Results (contd)

• Color coding, comparisons (to average, benchmark)
  most useful to staff
• Color coding, comparisons, HAI rates, number of
  HAIs, and number of days since last infection
  were most easy to understand
• SIR used in some hospitals (20), useful (38),
  easy to understand (26)
• HAI data most often presented HH, CLABSI
• Staff want environmental cleaning compliance
  data however, it is least likely provided to
  unit

30
Survey Results (contd)

• Differences in awareness of what data are
  presented (IPs vs. staff receiving data)
• Perceived differences in awareness of data and
  infection prevention compliance by type of staff
• Most aware and compliant nursing leadership,
  unit nurses
• Least aware and compliant physicians
• IPs share data most often with units and
  Infection Control Committee
• gt75 of respondents present HH, BSIs, SSIs, UTIs,
  VAPs
• gt75 of respondents present comparison HAI data

31
SSI Pilot SIR by Time Period
More infections than predicted
(statistically significant) Observed
number of infections similar to predicted
Fewer infections than predicted (statistically
significant) No infections ---SIR 1.00
when observed predicted
32
SSI Mini-Grant Program

• Any activities that support implementation of the
  NHSN Procedure-Associated Module, including but
  not limited to
• Equipment and services, such as administrative
  and informatics costs
• Example upgrading or modifying internal systems
• Training and education
• Example training for staff responsible for
  collecting and/or entering surgical site
  infection surveillance data
• Consultative and technical assistance
• Example programmer support to help create an
  electronic file to upload surgical procedure data
  directly into NHSN
• Administrative support

33
Awardees

• Applications reviewed by VDH and Virginia
  Hospital Healthcare Association (VHHA)
• 22 hospitals
• Total of 290,000
• Monies dispersed by July 2011

34
PERSPECTIVES FROM THE PARTICIPANTS
35
Sentara A Systems Approach

• Total funding 145,000 for System
• Technical assistance (IT) 124,000
• Training Infection Prevention Control (IPC),
  Data Auditors - 21,000
• Implementation goals
• Develop and implement an electronic export
  process for reporting of surgical procedure data
  directly into the NHSN database
• Provide training / technical assistance to staff
  to facilitate successful implementation of the
  exporting process
• Create super users / trainers who will
  disseminate the process throughout the Sentara
  Healthcare System

36
Sentara A Systems Approach

• Time Line
• Awarded mini-grants - May 2011
• Immediately developed Team (IT, Leadership,
  Finance, IPC) to address goals of funding
• IT Team began meeting with an action plan based
  on components (IT, Training) - June 2011
• Hired Consultant to develop IT components from
  PICIS OR Manager and background data fields -
  July 2011
• Pit Falls
• Other IT priorities (EPIC Go Live)
• Contracted IT staff
• Time line finances
• Experience
• Frustration

37
Next Steps for Sentara

• Activity reports (facility-specific) and unused
  funding submitted to VDH/VHHA
• November 15, 2011
• Implementation of final IT product
• November 2011
• Trial use of IT product by IPC
• December 2011
• Validation of process by IPC
• December 2011 - January 2012
• Use of product beginning with Jan 2012 surgical
  patient population with successful export of data
  to NHSN
• February 2012

38
Lessons Learned Other Facilities

• Electronic medical records are great but present
  documentation challenges
• Surgeons do not use ICD-9 codes
• Mapping of required denominator components time
  consuming
• IT needs special handling

39
Resources/Take Home Messages

• Challenge of converting CPT codes to ICD-9 codes
• Crosswalk soon available!
• NHSN forms for Procedure-Associated Module
• http//www.cdc.gov/nhsn/psc_pa.html
• Map entire facility in NHSN infections can
  happen anywhere
• Resources to Help Build Business Case for
  Electronic Upload (VDH document)
• Future training opportunities APIC-VA and NHSN

40
Acknowledgments

• VDH Dana Burshell, Carol Jamerson, Diane
  Woolard
• VHHA Barbara Brown
• APIC-VA
• SSI pilot participants
• SSI mini-grant recipients

41
The Purpose of Our WorkThe names of the
patients whose lives we save can never be known.
Our contribution will be what did not happen to
themDonald M. Berwick, MD, MPPFormer
President and CEO of IHICurrent Administrator of
CMS
Andrea.Alvarez_at_vdh.virginia.gov
804-864-8097 JPButler_at_sentara.com
757-388-3949