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The European protocol for surveillance of surgical site infections
Workshop “European surveillance of healthcare-associated infections: theory and practice”
Sofia, 26 – 27 November 2009
Outline
Definition of surveillance
Objectives of European surgical site infection (SSI)
surveillance
Case definitions for SSIs
Categories of surgical procedures under surveillance
The National Healthcare Safety Network (NHSN) risk
index
Information to be collected
Indicators of SSI incidence
Definition of surveillance
Ongoing, systematic collection, analysis, and
interpretation of health data
Closely integrated with the timely dissemination
to those who need to know
Application of the data to preventing and
controlling disease
Thacker SB, Berkelman RL. Epidemiol Rev 1998
Why surveillance of SSIs? At the level of the hospital Target infection control activity Drive change in practice Develop & underpin partnerships with clinical teams
At the regional/national level Follow up epidemiological trends in time Identify and follow up risk factors of SSIs Improve the quality of data collection
At the European level Work towards comparable surveillance methods Describe and monitor the epidemiology of SSIs at European
level Draw up European reference tables for inter-hospital comparisons of
risk-adjusted SSI rates Contribute to the extension of SSI surveillance in the European Union
General characteristics of European SSI surveillance
Patient-based surveillance
Prospective surveillance
Minimum period of three months recommended
Participation on voluntary basis
Case definitions for SSIs
To compare results must identify SSIs consistently
May not capture every SSI
European definitions based on CDC, USA, definitions
Widely adoptedInternational comparisons
European definitions of SSIs
Superficial incisionalinvolves only skin or subcutaneous tissueoccurs within 30 days of surgery (with/without implant)
Deep incisionalinvolves fascial or muscle layersoccurs within 30 days, implants within 1 year
Organ/spacepart of anatomy opened / manipulated infection appears related to surgeryoccurs within 30 days, implants within 1 year
A nonhuman-derived object,
material, or tissue (eg, hip
prosthesis) that is permanently
placed in a patient during an
operative procedure and is not
routinely manipulated for
diagnostic or therapeutic
purposes
Superficial Incisional SSI
Must meet one of the following criteria: 1. Purulent drainage from superficial incision 2. Organisms isolated from a culture of:
fluid or tissue from superficial incision
3. At least 1 sign or symptom of infection : pain, tenderness, localised swelling, redness, heat and Incision deliberately opened by surgeon 4. Clinicians diagnosis of superficial incisional
unless incision is
culture-negative
Deep Incisional SSI
Must meet one of the following criteria: 1. Purulent drainage from deep incision 2. Deep incision spontaneously dehisces or Incision deliberately opened by surgeon in the presence of at least 1 sign or symptom of infection: fever (>38 C), pain, tenderness 3. Abscess or other evidence of infection in deep
incision: direct examination or re-operation or histopathology or radiology
4. Clinicians diagnosis of deep incisional
unless incision
is culture-
negative
Organ/Space SSI
Must meet one of the following criteria: 1. Purulent drainage from a drain placed into the
organ/space 2. Organisms isolated from a culture of:
fluid or tissue in the organ/space
3. Abscess or other evidence of infection involving the organ/space: direct examination or re-operation or histopathology or
radiology
4. Clinicians diagnosis of organ/space SSI
Tips on applying the definitions of SSIs!
» Encourage medical and nursing staff to document clinical signs and symptoms in notes and bacteriology request forms
» Develop clear guidance on when a wound swab should be taken: there should be some signs or symptoms of infection
» Check significance of positive microbiology cultures with microbiologist
» Visually check wounds if information from clinical staff/patients notes is inconclusive
» If a patient is prescribed antibiotics do not assume these are for SSI – check with clinician
Categories of surgical procedures under surveillance
NHSN1 category
Description ICD-9-CM 2001 codes included in the category
CBGB Coronary artery bypass grafting with both chest and donor site incisions Chest procedure to perform direct revascularisation of the heart; includes obtaining suitable vein from donor site for grafting
36.10-36.14, 36.19
CBGC Coronary artery bypass grafting with chest incision only Chest procedure to perform direct vascularisation of the heart using, e.g, the internal mammary artery
36.15-36.17, 36.2
CHOL Cholecystectomy Removal of gallbladder; includes procedures performed using the laparoscope
51.03, 51.04, 51.2-51.24
COLO Colon surgery Incision, resection or anastomosis of the large intestine; includes large-to-small and small-to-large bowel anastomosis
45.00, 45.03, 45.41, 45.49, 45.50, 45.52, 45.7-45.90, 45.92-45.95, 46.0, 46.03, 46.04, 46.1-46.14, 46.43, 46.52, 46.75, 46.76, 46.91, 46.92, 46.94, 48.5, 48.6-48.69
CSEC Caesarean section 74.0-74.2, 74.4-74.99HPRO Hip prosthesis
Arthroplasty of hip81.51-81.53
KPRO Knee prosthesis Arthroplasty of knee
81.54, 81.55
LAM Laminectomy Exploration or decompression of spinal cord through excision or incision into vertebral structure
03.0-03.09, 80.50, 80.51, 80.59
1 National Healthcare Safety Network , USA
How to compare SSI rates? Case-mix adjustment needed
A possible approach the National Healthcare Safety Network risk index
It is weighted by information on:
Risk of contamination of the wound: wound contamination class
Patient’s physical condition: American Society of Anaesthesiology (ASA) physical status classification
Duration of operation
How to build the NHSN risk index? The wound contamination class
1. Clean:
uninfected operative wound and respiratory, alimentary, genital,
or urinary tract not entered; operative incisional wounds that follow non-
penetrating trauma should be included in this category, e.g. coronary artery
bypass graft
2. Clean-contaminated: respiratory, alimentary, genital, or urinary tract entered, under controlled
condition and without unusual contamination, e.g. cholecystectomy
3. Contaminated:
open, fresh, accidental wound; operations with major breaks in sterile technique;
incisions in which acute, non purulent inflammation encountered, e.g. open bone
fracture just after the trauma
4. Dirty or infected wound:
old traumatic wound with retained devitalised tissue and wound that involves
existing clinical infection or perforated viscera, e.g. revision of infected hip prosthesis
How to build the NHSN risk index? The physical status classification developed by the
American Society of Anaesthesiology (ASA score)
1. Normally healthy patient
2. Patient with mild systemic disease
3. Patient with severe systemic disease
4. Patient with incapacitating systemic disease that is a constant threat to life
5. Moribund patient who is not expected to survive for 24 hours with or without operation
How to build the NHSN risk index? Duration of operation
NHSN category 75th percentile cut-off value in hours
CBGB 5
CBGC 4
CHOL 2
COLO 3
CSEC 1
HPRO 2
KPRO 2
LAM 2
Cut-off values for duration of operative procedure categories
In case of a reintervention within
72 hours after the primary
operation, the duration of
reintervention need to be added
to the duration of the primary
operation
How to build the NHSN risk index?
Variables for stratification
NHSN risk indexStratification
points
Wound classification Class > 2 1
ASA score > 2 1
Duration of operation > 75th percentile 1
Stratification points for the variables of the NHSN risk index
Four levels of risk are defined (levels 0 to
3) using a combination of the three
variables
Information to be collected
Surgical Site Infection Surveillance
Operative Procedure Data Collection Form
GENERAL DATA
Hospital Code
Operative Procedure ID
Age at Date of Operation (years) |__|__|__|
Gender Male |__| Female |__| Unknown |__|
d d / m m / y y y y
Date of Admission |_____|________|______________| Discharge Status alive |__| death |__|
Date of Operation |_____|________|______________| NNIS Operation Code |__|
__|__|__|
Date of Discharge or |_____|________|______________| Date of Last Follow-Up in Hospital ICD-9-CM Operation Code |__|__| |__|__|Date of Last Follow- |_____|________|______________|Up Post Discharge
Surgical Site Infection Surveillance
Operative Procedure Data Collection Form
STRATIFICATION AND PREOPERATIVE DATA
Endoscopic Procedure? Yes |__| No |__| ASA Physical Status Classification
Normal healthy patient 1 |__|
Wound Contamination Class Mild systemic disease 2 |__|
Clean 1 |__| Severe systemic disease 3 |__|
Clean-Contaminated 2 |__| Incapacitating systemic disease 4 |__|
Contaminated 3 |__| Moribund patient 5 |__|
Dirty/Infected 4 |__|
Duration of Operation – Minutes |__|__|__| Were perioperative prophylactic antibiotics given?(from skin incision to skin closure) Yes |__| No |__|
Urgent/Elective Operation Urgent |__|
Elective |__|
Surgical Site Infection Surveillance
Operative Procedure Data Collection Form
INFECTION DATA
Surgical Site Infection
Did the patient develop a surgical site infection? Micro-Organism Code #1
No – Stop here |__| |__|__|__|__|__|__|
Yes – Answer remaining questions |__| Resistance Micro-Organism #1 |__|__|
Type of Surgical Site Infection Micro-Organism Code #2
Superficial incisional |__| |__|__|__|__|__|__|
Deep incisional |__| Resistance Micro-Organism #2 |__|__|
Organ/Space |__|
Micro-Organism Code #3
Date of Infection d d / m m / y y y y |__|__|__|__|__|__|
|_______|_______|______________| Resistance Micro-Organism #3 |__|__|
How to measure the occurrence of SSIs?
For each surgical procedure category and for each level
of the NHSN risk indexthree indicators
Cumulative incidence
Cumulative incidence, post-discharge surgical site infections excluded
Incidence density
Cumulative incidence of SSIs (1)
Definitionthe crude percentage of operations resulting in a surgical site
infection
How can be calculated Numerator: number of surgical site infections detected
within 30 days after the operation or 1 year for hip prosthesis and knee prosthesis
Denominator: the total number of operations
Cumulative incidence of SSIs (2)
Example: cholecystectomy 6 months of surveillance 01.01.2008 – 30.06.2008
Number of SSIs detected within 30 days after the operation: 7
Total number of operations: 500
Cumulative incidence: 7 / 500 * 100 = 1.4%
Cumulative incidence of SSIs (3)
Interpretation
This indicator gives the most complete picture for a given surgical
procedure category
but is highly dependent on the length of postoperative stay in
hospital and on the intensity of post-discharge surveillance
Cumulative incidence of SSIs, post-discharge SSIs excluded (1)
Definitionthe crude percentage of operations resulting in a surgical site
infection,before hospital discharge
How can be calculated Numerator: number of surgical site infections detected
before hospital discharge Denominator: the number of operations with known date of
hospital discharge
Example: cholecystectomy 6 months of surveillance 01.01.2008 – 30.06.2008
Number of SSIs detected before hospital discharge: 3Number of operations with known date of hospital discharge:
400
Cumulative incidence of SSIs, post-discharge SSIs
excluded: 3 / 400 * 100 = 0.8%
Cumulative incidence of SSIs, post-discharge SSIs excluded (2)
Interpretation
This indicator only considers surgical site infections detected in the
hospital, therefore is independent of post-discharge surveillance
Anyway it depends on the length of postoperative stay in hospital
Cumulative incidence of SSIs, post-discharge SSIs excluded (3)
Incidence density of SSIs (1)
DefinitionThe rate of surgical site infections detected before hospital
discharge standardized by the length of patient’s postoperative stay in
hospital It can only be calculated when the discharge date is known
How can be calculated Numerator: number of surgical site infections detected before
hospital discharge Denominator: the total number of postoperative patient-days
in hospital (sum of length of postoperative stay in hospital for patients with known date of hospital discharge)
Example: cholecystectomy 6 months of surveillance 01.01.2008 – 30.06.2008
Number of SSIs detected before hospital discharge: 3Total number of postoperative patient-days in hospital:
2,000
Incidence density of SSIs: 3 / 2,000 * 1,000 = 1.5/1,000 patient-
days
Incidence density of SSIs (2)
Interpretation
This indicator only considers surgical site infections detected in the
hospital and therefore it does not reflect the complete epidemiological
picture However, it is independent of post-discharge surveillance and
correctsfor differences in postoperative hospital stay Therefore this indicator may be more reliable for inter-
hospital or inter-network comparisons
Incidence density of SSIs (3)
Conclusions
The European protocol of SSI surveillance is a consolidated tool for SSI surveillance at European level; since the early 2000 it has been used by 14 European countries
It allows to develop a “common methodological language” between different countries and different networks
It contributes to get SSI incidence indicators in order to monitor epidemiological trends and to analyse inter-country and inter-hospital differences
