SURGICAL SITE INFECTION SURVEILLANCE Training for data management, quality assurance and reporting Scottish Surveillance of Healthcare Associated Infection Programme

Role of HPS To co-ordinate, facilitate and support the implementation of SSI surveillance To prepare Protocols To prepare data collection tools To support on-going data management and ensure quality data To collate and report the national data set Scottish Surveillance of Healthcare Associated Infection Programme

Objectives: To describe and apply all data management points pertinent to the local and national management of data To apply quality assurance requirements to SSI surveillance data To develop reporting and mechanisms of feedback for surgical site infection data Scottish Surveillance of Healthcare Associated Infection Programme

Introduction to Surveillance Surveillance is 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. The final link of the surveillance chain is the application of these data to prevention and control.Surveillance is 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. The final link of the surveillance chain is the application of these data to prevention and control. (Centers for Disease Control and Prevention 1988)

Objectives of surveillance Early warning  investigation of problems and intervention to control Monitoring trends Examining impact of interventions To gain information on quality of care Targeting resources

Scottish SSI Surveillance Programme - The Surveillance Cycle

Data collection completed at site Data are sent to the local surveillance coordinator Data are quality checked and anonymised (Patient identifying details removed) Data are sent to local nominated data transfer coordinator (if required) Data are sent to local nominated data transfer coordinator (if required) Forms sent to HPS by post or fax* Data scanned at HPS and database with reporting facilities fedback to hospital within 3 months Electronic data transfer to HPS* Collated for national reporting of SSI surveillance National Report Results fed back to hospitals

SURGICAL SITE INFECTION SURVEILLANCE Data Management Scottish Surveillance of Healthcare Associated Infection Programme

Aims of SSIS Programme Collect surveillance data on SSI’s to permit estimation of the magnitude of SSI risks in hospitalised patients Analyse and report SSI surveillance data and describe trends in infection rates Provide timely feedback of SSI rates to assist surgical units in minimising the occurrence of SSI’s Scottish Surveillance of Healthcare Associated Infection Programme

Data Management

What data? Scottish Surveillance of Healthcare Associated Infection Programme Each Division should undertake surveillance on at least two of the following operation categories, hip arthroplasty & caesarean section must be undertaken if performed at site. Generic Cardiac Surgery, CABG, Abdominal Hysterectomy, Caesarean Section, Major Vascular Surgery, Breast Surgery, Cranial Surgery. Orthopaedic Hip Replacement, Operations for Fractured Neck of Femur, Knee Replacement.

Data Collection Checking for Completeness and Accuracy Data Input ‘Local’ Reporting Quality Assurance Checking ‘National’ Reporting Data Management Process

Alternative Data Management Scenarios ‘Local’ Data Management Data Management at HPS Data Transfer The SSIS Database Scottish Surveillance of Healthcare Associated Infection Programme

Quality Assurance Workshop Collect completed forms Check forms for completeness and accuracy Process the data into the database Carry out QA Checking Present your findings Scottish Surveillance of Healthcare Associated Infection Programme

SURGICAL SITE INFECTION SURVEILLANCE Ensuring valid and reliable data through quality checks Scottish Surveillance of Healthcare Associated Infection Programme

AIM To promote valid and reliable data by performing thorough and appropriate quality checks Scottish Surveillance of Healthcare Associated Infection Programme

Objectives: To recognise the importance of appropriate data quality checks – both locally and nationally To understand how to perform quality checks on different aspects of data entry To be aware of the consequences of poor quality data Scottish Surveillance of Healthcare Associated Infection Programme

What would you look for in a quality product? A quality product is important to us all, SSI surveillance data is no different A lot of time and effort is put in by many people towards SSI surveillance data to ensure it is: –Valid –Reliable Everyone must have confidence in the data – that what is presented is a quality product !

Consequences of poor quality data Unreliable, invalid and subsequently inaccurate data Subjective outcome(s) Waste of time !

Consequences of poor quality data Overestimated infection rates Underestimated infection rates Inappropriate change to evidence based practice No change to practice / infection rates !

Implications for Divisions Clinical Governance Agenda Quality Improvement Standards (CSBS) Performance Assessment Framework National Reporting Public Concern

The “5 Ws” for quality What – SSI surveillance data Who – local and national teams When – frequency of data collection,collation and feedback Where – local and national teams Why – to ensure valid and reliable data

Quality checks Manual/visual checks Automated Form Processing Standard queries within Microsoft Access database

Manual/visual quality checks What Who When Where Why Data collection forms returned for collation to local co-ordinator –Forms visually checked for: Completeness Accuracy –Cleaning of data –Locating missing data Perform at least monthly, to avoid backlog Denominator checks also performed at this time, e.g. through theatre lists Essential to ensure data are accurate before sending to HPS and compiling reports for local feedback

Manual / visual quality checks Forms are received by SSHAIP team (HPS) from divisions (monthly) QA protocol is followed - forms are checked for: –Completeness –Accuracy Cleaning of data Locating missing data What Who When Where Why

AFP quality checks Forms scanned (within the quarter) ‘Validation rules’ (within Teleform) –Locating missing data Verification of fields prompted –SSHAIP team verify queries 1 st 100 forms verified field by field to be confident in level of accuracy Thereafter, monthly 10% of forms randomly checked field by field What Who When Where Why

Validation Rules Entries required Date frames set, e.g. age, date of admission, date of operation Time frames set, e.g. start time of operation, completion time of operation, date of confirmed SSI

MS Access Standard Query - Quality Checks Standard queries written include: –Lookup tables, e.g. hospital codes, OPCS4 codes –‘Value’ checks, e.g. sex, category of procedure –Date, time and value frames set, e.g. date of operation, BMI –Accuracy checks, e.g. criteria for SSI and when SSI detected - against SSI present and date frames Queries run and verified (e.g.monthly) by SSHAIP team Anomalies checked, contact with local co- ordinator What Who When Where Why

Additional QA checks Annual case note review –20 random case notes reviewed against database –SSHAIP team and local co-ordinators Permission for access –A report will be fedback to all divisions Denominator checks –In addition to division denominator checks the SSHAIP team will liaise with ISD to obtain denominators by hospital by procedure What Who When Where Why

Summary The importance of understanding: –The processes for data entry –The many data quality checks –The responsibilities for quality checks, both locally and nationally –The consequences of poor quality data

Data Reporting Workshop Workshops to: –Be familiar with reports that can be obtained through MS Access database –Consider use of these reports for the local feedback process –Raise any issues with these reports –Analyse reports to ensure they provide valid and reliable data

Reporting data

Reporting of data Objectives: To develop an understanding of the local and national mechanisms of reporting SSI data To describe risk adjusted reporting To examine the different mechanisms which can be utilised for reporting data

Reporting ?

Requirements for successful surveillance Commitment of senior managers Commitment of a multidisciplinary staff A suitable method for data collection A suitable method for reporting

The “5 Ws” of data reporting What ? Who ? When ? Where ? Why ?

What ? – Feedback of data Graphs Tables Descriptive statistics Inferential statistics

What ? Risk Index for SSI Surveillance SSI rates, by surgical procedure/category, which will be stratified by risk index. The NNIS risk index will be used for this. This index scores each procedure according to the presence or absence of three risk factors at the time of surgery and scores range from 0 (none of the factors present) to 3 (all of the factors present). The risk factors are: –ASA score>=3 –Wound classified as contaminated or dirty –Duration of operation

NNIS Risk Index Graph EXI T

Who? – Presenting the data All stakeholders: All multidisciplinary involved in the surgical care pathway –Surgeons –Infection control staff –Managers/ resources –HPS

When ?Where ? Regular feedback: –Active –Passive Denominator At least quarterly Locally: by individual (anonymised) Nationally: HPS collate and present by Division

Why ? Prevention (Haley et al) –Engaged clinicians –Motivated Infection control staff –Intensive surveillance programme Hawthorne effect Early identification of problem trends/ outbreaks Resource allocation

Wound surveillance nurse administrates the project Wound surveillance nurse identifies patients from theatre lists Demographic details…completed by wound surveillance nurse on the ward pre-op Patients with identified wound problems are seen at wound surveillance clinics, or at home by the wound surveillance nurse for wound review Patients are seen at wound surveillance clinics, or at home by the wound surveillance nurse at day 30 post-op for wound review Operative details…completed by wound surveillance nurse on the ward post op Patients have a 24 hour answer service telephone number to call with wound problems. Primary care staff also liaise with wound surveillance nurse Daily visits to all surgical wards to carry out wound checks Wounds are checked before discharge from hospital Data are managed and collated by the wound surveillance nurse Data are graphed and fed back to the surgeons, nurses and infection control team on a monthly basis

Conclusion SSI rates are key quality indicators for surgery Data must be complete Data must be reliable and valid Data must be reported back to clinicians Data must be acted upon

Summary Overviewed data management issues pertinent to the local and national management of data Developed an understanding of the local and national quality assurance requirements Aware of the importance of reporting and mechanisms of feedback of surgical site infection data