Surgical Site Infection Reporting in Illinois Using NHSN

March 2010

Illinois Department of Public Health

TO DO LIST

1. If your facility did not report central line-associated bloodstream infections (CLABSIs), you need to enroll in NHSN.

2. For instructions refer to:

APIC Chicago 10_24_08 NHSN How To.pdf

prepared by Sylvia Garcia-Houchins

Contact IDPH: jessica.ledesma@illinois.gov

TO DO LISTEDIT MONTHLY REPORTING PLAN

For those who have already been reporting CLABSI data to NHSN, the monthly reporting plan needs to be edited to include SSI reporting.

1.Add a plan for each month (12 total)

2.Procedures to include are KPRO and

CABG (CBGB & CBGC)

5

• Navigation Bar Reporting Plan Add

• Choose month (Apr) and year (2010)

• Add rows until all indicators are entered

– SSI for inpatient CABG (CBGB/CBGC) and Knee Prosthesis (KPRO)

• After 1st month entered, SAVE, then ‘Copy from Previous Month’

• SAVE after each “copy” action

TO DO LISTCONFERRING RIGHTS TO INCLUDE SSI

REPORTING

• Modify Conferring Rights screen

Navigation Bar Group Confer Rights

– Find IDPH, highlight it, and click confer rights

1.Procedures to include are KPRO and

CABG (CBGB & CBGC)

7

IDPH

Step 1

Step 2: Surgical Procedures: CBGB, CBGC, KPRO

Note for previous slide (9): COLO and HPRO are not being reported to IDPH; this is just an

example.

Also, the initial month (“from”) should be 4 (April) and the year 2010; ending month

(“to”) should be left blank.

There will be one row for each procedure, for a total of three rows (CBGB, CBGC, KPRO).

Step 3: Copy

Summary Data =

Procedure Denominator

Events Data

3.

Trash Can

4. Don’t Forget to SAVE

Step 4

14

• View rights with patient identifiers

• View rights for monthly reporting plan

• View rights for annual hospital survey

• View rights for data analysis

• In plan SSIs: CBGB,CGBC, KPRO - from 04/01/2010

• Link infection events with denominators

SAVE Before Exiting

Minimum Surveillance Requirement for NHSN SSI Reporting in Illinois Hospitals

Surgical site infection (SSI) cannot be reliably identified from laboratory data alone as the diagnosis depends on the

presence of signs and symptoms of infection in the wound.

Minimum Surveillance Requirement

• SSI identified during Index Hospitalization

• SSI identified upon readmission to same hospital where initial surgical procedure performed

• SSI detected solely by post-discharge surveillance (optional)

Minimum Surveillance Requirement

• SSI identified during Index Hospitalization

Prospective surveillance of patients with designated operative procedures. Patient is followed through index hospitalization.

Minimum Surveillance RequirementSSI identified during Index Hospitalization

• Review of microbiology reports for positive blood cultures and submission of wound or wound-like cultures (abscess, soft tissue, etc) for evidence of pus (moderate or many white blood cells or polymorphonuclear leukocytes on gram stain) or bacterial growth and

• one or more of the following methods must be used for SSI surveillance:– Infection control rounds on nursing units– Routine review of admission/transfer/discharge data for:

• transfer of patients who have undergone a procedure to a more acute care setting (e.g., ICU);

• return to the OR; and/or • prolonged stay (based on a nationwide inpatient sample from the Agency for

Healthcare Research and Quality [AHRQ], expected inpatient duration of stay following CABG is 9.3 days and 4 days following total knee replacement)

– Operating room reports of surgeries and repeat surgery on a patient who has undergone total knee arthroplasty or coronary artery bypass surgery

– Electronic surveillance system

Minimum Surveillance RequirementSSI identified upon readmission to same hospital where

initial surgical procedure performed

According to the NHSN SSI module protocol, the time period for tracking SSIs depends on the type of operative procedure performed. For those operative procedures where no implant is left in place, the follow-up period is 30 days. For those operative procedures where an implant is in place, such as a CBGB/CBGC where sternal wires or clips are placed, and for all KPROs, the follow-up period is one year (365 days).

Minimum Surveillance RequirementSSI identified upon readmission to same hospital where

initial surgical procedure performed

Each hospital must establish a protocol for identifying patients who have an implant placed and are readmitted within 365 days of the index surgery. According to the NHSN definition an implant is a nonhuman-derived object, material, or tissue that is permanently placed in a patient during an operative procedure and is not routinely manipulated for diagnostic or therapeutic purposes. Examples include: porcine or synthetic heart valves, mechanical heart, metal rods, mesh, sternal wires, screws, cements, and other devices.

Minimum Surveillance RequirementSSI identified upon readmission to same hospital where

initial surgical procedure performed

Routine review of admission/transfer/discharge data to identify these patients and at least one or more of the following methods must be used for SSI surveillance:

o Review of microbiology reports (wound or wound-like cultures and blood cultures)

o Infection control rounds on nursing units

o Electronic surveillance system

Minimum Surveillance RequirementSSI detected solely by post-discharge surveillance

• SSI detected solely by post-discharge surveillance can be entered into NHSN, however IDPH will not include these cases in the calculation of hospital-specific SSI rates. This will allow for a fair comparison of hospitals and not penalize facilities with more robust surveillance systems.

• According to the NHSN SSI module protocol, SSI identified at a facility other than the hospital where the initial surgical procedure was performed is categorized as being detected through post-discharge surveillance.

Documenting SSI Surveillance Method

The Surgical Site Infection (SSI) form used in the NHSN SSI reporting module collects information concerning the detection method used to identify the SSI.

• This field is named “Detected”. There are three possible reporting options:– A: SSI was identified before the patient was discharged

from the facility following the operation.– P: SSI was identified during post-discharge surveillance.

This includes SSIs identified at another facility.– R: SSI was identified due to patient readmission to the

facility where the operation was performed.

Contact Information

nhsn@cdc.gov

lauren.gallagher@illinois.govjessica.ledesma@illinois.gov