Surgical Site Infections: SSI: I hear the words, but are we talking about the same thing? Surgical Site Infections: Simply Complicated Wendy Runge, RN, BScN, CIC Infection Prevention and Control, Calgary Health Region Safer Healthcare Now! Western Node

The SSI phenomena: A simply complex problem

Defining SSI: Getting on the same page

CDC/NNIS SYSTEM Guideline for Prevention of Surgical Site Infection, 1999 includes: Definition criteria for inclusion (or not!) Classification of infection depth

SSI depth CDC/NNIS SSI CLASSIFACATION SYSTEM

SSI Definitions Each depth has a set of definition criteria Each case must meet the definition criteria EXACTLY Extended surveillance period for implant surgery (12 months)

CDC/NNIS SYSTEM NNIS reports: Criteria for risk stratification Provides risk adjusted ‘Benchmark’ rates for specific procedures

NNIS Rates Risk- adjusted NISS ‘Benchmark’ infection rate for hip prosthesis: 0 = 0.54% 1 = 1.24% 2, 3 = 2.05% (50th percentile rates; taken from the 1992-2003 NNIS report)

It all started here…

Case Study: Mrs. D 73 year old female with IDDM, CAD, COPD and osteoarthritis Right total hip performed in March/2005 Operative Details: Intra operative cultures neg Procedure took 2:30 Patient ASA score was ‘3’ Wound classification = Clean

Case Study: Mrs. D Is Mrs. D a high surgical risk patient? What is her NNIS risk score?

Does the drainage indicate an infection? Mrs. D (cont.) Uneventful surgery and hospital recovery, with discharge on day 6 Wound was ‘well approximated’ with ‘scant serous discharge’ Does the drainage indicate an infection?

Mrs. D (cont.) At 14 days post op, Mrs. D presents to ER with R hip redness and some localized edema No drainage noted, no cultures The ER doc diagnoses ‘Cellulitis’ and starts her on a course of Keflex Is this an infection?

Mrs. D (cont.) 4 weeks post op, Mrs. D presents in ER again, this time with hip pain, fever and an elevated WBC She is admitted to hospital with the diagnosis “Query septic joint” Joint aspirate cultures are negative Is this an infection?

Mrs. D (cont.) Mrs. D’s urine cultures grow Pseudomonas aeruginosa Right hip xrays report no significant findings Her UTI is treated and she is discharged

Mrs. D (cont.) 3 months post op, Mrs. D again presents with hip pain, fever and an elevated WBC R hip Xray reports areas of lucidity and possible loosening of the prosthesis Is this an infection?

Mrs. D (cont.) Urine culture is negative, CXR shows no acute changes CT scan of her R hip reports a fluid collection in the subcuticular tissue The collection is aspirated: Straw-colored fluid Cultures = ‘no growth’ Is this an infection?

Mrs. D (cont.) Joint aspirate grew Coagulase negative staphylococcus She is admitted for ‘I&D of R Hip’ Diagnosis: ‘Query Infected R Hip’ Is this an infection?

Mrs. D (cont.) Surgical Procedure: Evacuation of seroma, debridement and liner exchange R hip Surgeon’s Operative report: Evacuation of Seroma, devitalized tissue debrided, joint irrigated and liner exchanged (no pus seen)

Mrs. D (cont.) 2:4 intraoperative tissue cultures grow Coagulase negative staphylococcus A PICC is inserted course of Vancomycin is started Is this an infection? If yes, then what depth?

Mrs. D (cont.) What are some possible reasons that Mrs. D developed a surgical site infection? What is the probable source of the infection?

Mrs. D (cont.) Possible outcomes: Cure – no further problems Premature loosening and early revision Excision arthroplasty with 2-stage revision

Surveillance "the ongoing, systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know (CDC )". Dr. Peter Riben, Infection Control Specialist BC Provincial Infection Control Network Safer Healthcare Now! Western Node

Process of Surveillance Determine an Objective Identify variations in the rate within a clinically relevant time frame

Process of Surveillance Define the Event NNIS - superficial, deep, organ space

Process of Surveillance Identify the data sources, who collects the data, how frequently, triggers and timing

Process Surveillance Data collection form Numerator Denominator

Process of Surveillance Analyze, interpret, disseminate the information

Discussion Table discussion on how surveillance is viewed at each team level Report out