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

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: 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 CDC/NNIS SSI CLASSIFACATION SYSTEM

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

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

10. It all started here…

11. Case Study: Mrs. D 73 year old female with IDDM, CAD, COPD and osteoarthritis 73 year old female with IDDM, CAD, COPD and osteoarthritis Right total hip performed in March/2005 Right total hip performed in March/2005 Operative Details: 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? Is Mrs. D a high surgical risk patient? What is her NNIS risk score? What is her NNIS risk score?

13. Mrs. D (cont.) Uneventful surgery and hospital recovery, with discharge on day 6 Uneventful surgery and hospital recovery, with discharge on day 6 Wound was ‘well approximated’ with ‘scant serous discharge’ Wound was ‘well approximated’ with ‘scant serous discharge’ Does the drainage indicate an infection? 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 At 14 days post op, Mrs. D presents to ER with R hip redness and some localized edema No drainage noted, no cultures No drainage noted, no cultures The ER doc diagnoses ‘Cellulitis’ and starts her on a course of Keflex The ER doc diagnoses ‘Cellulitis’ and starts her on a course of Keflex Is this an infection? 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 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” She is admitted to hospital with the diagnosis “Query septic joint” Joint aspirate cultures are negative Joint aspirate cultures are negative Is this an infection? Is this an infection?

16. Mrs. D (cont.) Mrs. D’s urine cultures grow Pseudomonas aeruginosa Mrs. D’s urine cultures grow Pseudomonas aeruginosa Right hip xrays report no significant findings Right hip xrays report no significant findings Her UTI is treated and she is discharged 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 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 R hip Xray reports areas of lucidity and possible loosening of the prosthesis Is this an infection? Is this an infection?

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

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

20. Mrs. D (cont.) Surgical Procedure: Evacuation of seroma, debridement and liner exchange R hip 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) 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 2:4 intraoperative tissue cultures grow Coagulase negative staphylococcus A PICC is inserted course of Vancomycin is started A PICC is inserted course of Vancomycin is started Is this an infection? Is this an infection? If yes, then what depth? If yes, then what depth?

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

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

24. Surveillance Safer Healthcare Now! Western Node "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

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

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

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

28. Process Surveillance Data collection form Data collection form Numerator Numerator Denominator Denominator

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

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