1. December 5-6, 2011 Cherylanne Zeumault Jeanette Harris

2.  SSI & CAUTI  CAUTI…..not much is new – but if you have questions…we can help  SSI…..LOTS new in 2012  CMS: Colon surgery  CMS: Abdominal Hysterectomy  Along with all the Washington Mandatory  Reportable surgeries CARD,CBGB,CBGC,HPRO,HYST,KPRO,VHYS http://apps.leg.wa.gov/rcw/default.aspx?cite=43.70& full=true#43.70.056 http://apps.leg.wa.gov/rcw/default.aspx?cite=43.70& full=true#43.70.056

3.  The new NHSN Patient Safety Component Manual  New this month http://www.cdc.gov/nhsn/library.html

4.  Add to your monthly reporting plan – a MUST  Data Verification  800 hospitals  Data Quality Output Options – check yourself  Go to Output Options – Advanced – Data Quality, CDC defined Output:

6.  NEW REPORTING STEPS………….  Click on Event – Incomplete  Click on Missing PA Events tab  Check report NO EVENTS next to SSI then “save”

8.  It’s YOUR data  It’s more meaningful, actionable  EXTERNAL SCRUTINY  Plus it helps everyone else for better benchmarking  Identified  Mis-mapped facility locations – leads to incorrect benchmarking  Incomplete denominators  Misidentified lines  Misconceptions of definitions  Missed/Overcalled cases

9.  Number of beds?  Location mapping?  New reporters? Are they all up do date?  Manual Counting  Electronic Counting Do spot checks  SSI Procedures Are they complete? Look for a secondary source for validation How to find procedures NOT PRIMARILY CLOSED? Check procedure duration and ASA score for all CBGB and CBGC IT can change things and you wouldn’t know it

10.  Non-autologous transplants –  No longer needed  Estimated Blood loss for C-Sections –  No longer needed  Implants: Temp or permanent  Porcine or synthetic valves  Mechanical heart  Metal rods, screws, sternal wires, cements, internal staples, hemoclips, other

11.  5 procedures that have additional risk  CSEC, Fusion/Refusion  HPRO  KPRO  Height in ft and inches or meters  Weight in pounds or Kg  C-Sections: Hours of labor in the hospital  Length of time beginning of active labor as an inpatient to delivery

12.  FUSN/RFUSN  Diabetic Y/N  Spinal Level  Approach  HPRO  Which type - TP, PP, TR, PR  KPRO  Which type – Primary, Revision (total or partial)

13.  Infection?  Determine which procedure could be associated  If it’s not clear, use the Principal Operative Procedure Selection Lists (Table 3 in the manual)

14.  SSI “Detected” Field  No more “P” (post-discharge)  Instead, “Detected” will have 2 values RO: if SSI identified due to patient admission to a facility other than where the op was performed RF: if SSI was identified due to patient readmission to the facility where the op was performed  Secondary BSI is required if there was a +BC  The organisms MUST be the same  Linking

15.  The SIR is an indirect standardized method for summarizing HAI across any number of stratified groups of data.  The SIR is the number of observed infections divided by the predicted (or statistically expected) number of infections.  The expected number is based on the national NHSN average, the number of procedures performed by a hospital and the historical data for those procedures.

16.  A SIR of 1.0 means the observed number of infections is equal to the number of expected infections.  A SIR above 1.0 means that the infection rate is higher than that found in the "standard population." For HAI reports, the standard population comes from data reported by the hundreds of U.S. hospitals that use the NHSN system. The difference above 1.0 is the percentage by which the infection rate exceeds that of the standard population.  A SIR below 1.0 means that the infection rate is lower than that of the standard population. The difference below 1.0 is the percentage by which the infection rate is lower than that experienced by the standard population.

17.  IPist notices that “Hospital X” has a higher number of KPRO infections than normal (more than one surgeon). IPist….PREPARES FOR BATTLE  During discussing with the Surgery Committee…Comments from surgeons  “We have harder cases than hospital “Y”  “We do more cases than hospital “Y”  “We don’t like being compared to hospital “Y”!!  IPist notes:  This is your SIR. It is 1.8  That means that you are 80% higher than other similar hospitals – NATIONWIDE  FYI….Hospital “Y” is not in your group (neener, neener)  You are compared to other similar hospitals with similar beds, risk factors, med school affiliation, etc.

18.  Surgery rebuttle:  “What’s our rate compared to the National Rate? What’s the benchmark?  Ipist: There is no more “benchmark”  There is only Standardized Infection Ratio  This means that you are compared to other surgeons/hospitals with patients with similar risk factors that include more than just ASA score and wound class  This is a BETTER and MORE ACURATE method of comparison  You’re SIR of 1.8 means that you have 80% more infections than similar hospitals across the nation  Surgery: So we really DO have more infections?  Ipist: YES  Surgery Committee Chair: I suggest we get a team together to see what’s going on

19.  RCA discovered that there were variations in practices that contributed to these infections  Surgery Committee Report:  More help during surgery  Control the number of staff in surgery suite  Positioning  Draping  Dressings  Staff training  Outcome: no infection since (6 months)