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Target serious SSIs in reporting systems

Panel tries to 'level playing field' on tough issue

A "tool kit" created by an expert panel on hospital infection reporting laws addresses the controversial issue of surgical site infections (SSIs), advising ICPs and state legislatures to focus tracking and reporting efforts on the most severe SSIs to ensure fair comparative data.

"In terms of surgical site infection reporting, only target those that occur during the index admission and only those inflections that require readmission," says Raymond Chinn, MD, hospital epidemiologist for Sharp Memorial Hospital in San Diego, and a member of the panel that developed the tool kit. "One of the major arguments in the past is that certain health care systems that have well defined case-finding strategies that include everything will come out with higher [infection rates.] So in order to level the playing field, we said maybe what we should do is focus on the more severe infections."

The tool kit was created by a working group that includes members from the Association for Professionals in Infection Control and Epidemiology, the Centers for Disease Control and Prevention, the Council of State and Territorial Epidemiologists, and the Society for Healthcare Epidemiology of America. The tool kit provides guidance on the components necessary for a meaningful reporting system in order to assist states and health care facilities facing legislative mandates.

The working group emphasizes the importance of SSI definitions, of being consistent in case-finding methodologies, and of applying risk-adjustment strategies when comparing outcome data. Each state should review the scope of surgical procedures performed by health care facilities and choose those surgical procedures for SSI surveillance that are performed with adequate frequency to permit meaningful comparisons between institutions, the panel recommended. The following are examples of procedures that are reasonable options for public reporting of SSIs:

coronary artery bypass surgery,
colon resection,
total hip arthroplasty,
total knee arthroplasty,
laminectomy,
total abdominal hysterectomy.

Fair to compare

A focus on more serious infections will still yield the bulk of adverse outcomes without putting more aggressive surveillance programs in a bad light. "It does capture the majority of infections," says Shannon Oriola, RN, CIC, lead ICP at Sharp Memorial Hospital in San Diego, and a member of the panel that developed the tool kit. "What you may not pick up with that is a superficial infection that may not even be cultured or need treatment. But you're capturing deeper infections, which we can all capture. So in fairness, everybody would be able to collect the same data equally so there is uniformity."

Of course, many facilities will continue to monitor superficial infections to evaluate their program, but they would not be bound to include them in reporting systems focused on severe SSIs. The working group also recommended that states use CDC definitions and risk indexes (e.g., wound class, duration of surgery) to identify and report SSI rates.

The working group acknowledged that a comprehensive surveillance program for detection of SSIs may include post-discharge surveillance for identification of SSIs. "However, there is significant variability in institutional methodology in obtaining data on patients who develop SSIs after discharge but who do not require rehospitalization for management of their SSIs (usually superficial infections), either at the original facility where the surgical procedure was performed or at another facility," the guidelines state. "Therefore, in order to improve the likelihood of having meaningful comparative data for public disclosure and until there is consensus on the optimal post-discharge surveillance methodology, the working group recommends that the initial scope of SSI surveillance for public reporting include both patients who develop SSIs during initial hospitalization, and patients who develop SSIs following discharge and require readmission to the hospital."

"You have to set a minimum," says Eddie Hedrick, BS, MT(ASCP), CIC, emerging infections coordinator at the Missouri state health and a member of the panel that developed the tool kit. "At a minimum, you evaluate readmissions. When you think about it, most people with deep infections will be readmitted. The things you will miss are the stitch abscesses and some of the real superficial stuff, which isn't a big deal. We feel this will capture the majority of things. The other thing we put in our [state] law was that hospitals are now required to notify another hospital should they find one. So if Hospital A finds [an SSI] from Hospital B, they have to call them and tell them about it."

Indeed, the tool kit guidelines note that "not all patients who develop SSIs requiring hospitalization are readmitted to the same institutions where the surgical procedures were performed; therefore, institutions should have a process that enables personnel charged with data collection to inform the original facility where the patient's surgical procedure was performed of the development of SSI."

In general, patients that develop SSIs can be identified using the following techniques and data sources:

Review of operating room logs for debridement and surgical drainage of abscesses.
Review of interventional radiology logs for percutaneous drainage of abscesses.
Review of microbiology laboratory's daily log of positive cultures.

(Editor's note: The complete tool kit is available at the APIC web site at www.apic.org.)