All About Surgical Site All About Surgical Site InfectionsInfectionsLessons learned from the SSI surveillance pilot, SSI mini grant program, and the data presentation collaborative

Andrea Alvarez, MPHHAI Program Coordinator

Virginia Department of HealthJacqueline P. Butler, CIC

Dir, Infection Prevention & ControlSentara HealthcareNovember 10, 2011

SSI Surveillance Pilot: SSI Surveillance Pilot: PurposePurpose

Public reporting expectations increasing Multiple factors to consider when

choosing a SSI for public reportingTroubleshoot issues with

surveillance definitionsQuantify time requirements for

surveillanceGather lessons to help prepare

other facilities for reporting

Perceived Pilot BenefitsPerceived 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

SSI Pilot: Methods – Selecting SSI Pilot: Methods – Selecting Hospitals and ProceduresHospitals 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.)

Pre-SurveyPre-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

Methods - TrainingMethods - TrainingPartnership 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 Q&A Data import discussions Feedback of data

Some Surveillance Some Surveillance PointersPointers

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

NHSN ClarificationsNHSN ClarificationsDeep 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

Methods – Data ReportingMethods – Data ReportingMonthly entry of procedures and

infection events into NHSN Procedures from July – Dec 2010 with 6

months of post-discharge surveillanceQuarterly 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

Electronic Upload Methods: Electronic Upload Methods: ASCII FileASCII FileComma 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/

ImportingProcedureData_current.pdf

Electronic Upload Methods: Electronic Upload Methods: CDACDA

*List compiled by APIC

SSI Pilot: Time and Effort per SSI Pilot: Time and Effort per FacilityFacility

2010 2011*

*Readmission/post-discharge only

SSI Pilot: Time and Effort per SSI Pilot: Time and Effort per PersonPerson

2010 2011*

*Readmission/post-discharge only

Results: SCIP DataResults: 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

ProcedureSCIP1

(%) SCIP2 (%)SCIP3 (%) Total

(%) Minutes

CABG 98.6 100.0 97.2 98.6 19

HPRO 99.4 100.0 97.0 98.8 8

KPRO 97.2 99.9 96.9 98.0 12

Total 98.4 100.0 97.0 98.5 13

Results: SSIs IdentifiedResults: SSIs Identified2,388 procedures conducted25 SSIs included in SIR calculation

Secondary infections are not included in SIR - All CABG (N=5)

64% CABG, 24% KPRO, 12% HPRO ASA score and duration of procedure highest for

CABG 3 occurred > 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

Post-SurveyPost-Survey14/18 facilities responded (78%)Facilities more prepared for public

reporting Staff review SSI definitions more closely

IT changes Many facilities changing or considering

changing vendorsChanges to administration’s

prioritization of SSI surveillance (4 facilities)

No change in IPs’ perspective of the magnitude of the problem of SSIs in their facility

Benefits to ParticipationBenefits to Participation93% - Helped to prepare for future

reporting requirements79% - Gained more experience in

NHSN data entry57% - 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

Barriers Encountered Barriers Encountered 50% Learning curve

Data entry Importing data

43% Time/resource limitations Data entry Staffing

29% No barriers14% Post-discharge surveillance14% Consistency between

facilities

Electronic Upload to NHSNElectronic 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

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

Lessons Learned / Lessons Learned / ChallengesChallenges

Lessons Learned / Lessons Learned / ChallengesChallengesOperating room system capability and

compatibilityWriting 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

PERSPECTIVES PERSPECTIVES FROM THE FROM THE

PARTICIPANTSPARTICIPANTS

Experiences of a Large Experiences of a Large SystemSystem

Sentara Healthcare (SH): >23,000 staff, >100 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.

Timeline of Sentara’s Pilot Timeline of Sentara’s Pilot PeriodPeriod

Calm down Education – June 9, 2010 Define current surveillance process for CABG Develop a Team (IT, Contracted Vendor, Cardiac

Auditors, Leadership, IP&C) 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 – ongoing…Why stop a good process?

Sentara’s ExperiencesSentara’s ExperiencesPit 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:PositiveDemonstrated SH’s ability to address

issues of mandatory reporting

Building in a CollaborativeBuilding in a CollaborativeRequirement of ARRA fundingCreate a project to be flexible and

responsive to acute care IPs’ workload Collecting data presentation templates Sharing best practices for data feedback

Monthly conference callsSurvey given to IPs and unit-specific

staff to capture the various perceptions of data utility

Data Presentation SurveyData 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

Data Presentation Survey Data Presentation Survey Results: IP and Staff Results: IP and Staff PerceptionsPerceptions

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

Survey Results (cont’d)Survey Results (cont’d)Color coding, comparisons (to average,

benchmark) most useful to staffColor 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, CLABSIStaff want environmental cleaning

compliance data; however, it is least likely provided to unit

Survey Results (cont’d)Survey Results (cont’d) 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 >75% of respondents present HH, BSIs, SSIs, UTIs,

VAPs >75% of respondents present comparison HAI data

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

SSI Pilot SIR by Time SSI Pilot SIR by Time PeriodPeriod

SSI Mini-Grant ProgramSSI 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

AwardeesAwardeesApplications reviewed by VDH and

Virginia Hospital & Healthcare Association (VHHA)

22 hospitalsTotal of ~$290,000Monies dispersed by July 2011

PERSPECTIVES PERSPECTIVES FROM THE FROM THE

PARTICIPANTSPARTICIPANTS

Sentara: A Systems Sentara: A Systems ApproachApproachTotal funding: $145,000 for System

Technical assistance (IT) – $124,000Training [Infection Prevention & Control (IP&C), 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

Sentara: A Systems Sentara: A Systems ApproachApproachTime Line: Awarded mini-grants - May 2011 Immediately developed Team (IT, Leadership, Finance,

IP&C) to address goals of funding IT Team began meeting with an action plan based on

components (IT, Training) - June 2011Hired Consultant to develop IT components from PICIS

OR Manager and “background” data fields - July 2011Pit Falls:Other IT priorities (“EPIC Go Live”)Contracted IT staffTime line – financesExperience:Frustration

Next Steps for SentaraNext Steps for SentaraActivity 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 IP&C December 2011

Validation of process by IP&C December 2011 - January 2012

Use of product beginning with Jan 2012 surgical patient population with successful export of data to NHSN February 2012

Lessons Learned: Other Lessons Learned: Other FacilitiesFacilities

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”

Resources/Take Home Resources/Take Home MessagesMessages

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

AcknowledgmentsAcknowledgmentsVDH: Dana Burshell, Carol

Jamerson, Diane WoolardVHHA: Barbara BrownAPIC-VASSI pilot participantsSSI mini-grant recipients

The Purpose of Our Work:“The names of the patients

whose lives we save can never be known. Our

contribution will be what did not happen to them”

Donald M. Berwick, MD, MPPFormer President and CEO of

IHICurrent Administrator of CMS

Andrea.Alvarez@vdh.virginia.gov: 804-864-8097JPButler@sentara.com: 757-388-3949