1. 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

3. The SSI phenomena: A simply complex problem

4. Defining SSI: Getting on the same page

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

6. SSI depth
CDC/NNIS SSI CLASSIFACATION SYSTEM

7. 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)

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

9. 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 NNIS report)

10. It all started here…

11. 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

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

13. 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?

14. 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?

15. 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?

16. 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

17. 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?

18. 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?

19. 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?

20. 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)

21. 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?

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

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

24. 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

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

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

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

28. Process Surveillance
Data collection form
Numerator
Denominator

29. Process of Surveillance
Analyze, interpret, disseminate the information

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