EVALUATION OF SURGICAL SITE INFECTION (SSI)
SURVEILLANCE PROGRAMS IN THE ERIE-ST.
CLAIR LHIN
PHO IPAC Exchange, October 2014
E. Vitale
MPH, B. Sc., MLT, CIC
OBJECTIVES
1. Provide an overview of 5 participating facilities
2. Describe the purpose of the SSI surveillance Program
Evaluation
3. Review the steps involved in program evaluation as
applied to SSI surveillance, including the development of
a logic model
4. Analyze key results and recommendations based on
evaluation
5. Outline next steps
OVERVIEW OF 5 FACILITIES
Bluewater
Health
13% surgical
beds
Ortho,
general, obgyn
3.5 ICPs
ChathamKent
Health
Alliance
Leamington
District
Memorial
Hospital
13% surgical
beds
Ortho,
general, obgyn
3 ICPs
100% mixed
med-surg beds
Ortho, general.
Ob-gyn,
plastics
1 ICP
Windsor
Regional
Hospital
Met
Campus
16% surgical
beds
Ortho,
general, obgyn
3.5 ICPs
Hotel Dieu
Grace
Hospital
23% surgical
beds
Ortho,
general,
cardiac,
thoracic,
neuro,
plastics,
trauma
3 ICPs
PURPOSE OF THE EVALUATION
PURPOSE OF THE EVALUATION
1. Gain knowledge about the SSI surveillance programs
2. Help improve or modify existing SSI surveillance
programs
3. Determine effects of the SSI surveillance programs
4. Affect program participants (particularly members of
the surgical program) by acting as a catalyst for
change
EVALUATION METHODS AND DESIGN
EVALUATION METHODS AND DESIGN
Literature review of best practices for SSI surveillance including programs in other jurisdictions
or countries
Development of an assessment / evaluation tool (see logic model)
Detailed surveys with ICP leads, as well as surveying other surgical team members
An analysis of the SSI surveillance programs data utilizing the assessment / evaluation
tool
Review infection rates / trends in each facility
LOGIC MODEL
Resources
Activities
Short term
Outcomes /
Outputs
Intermediate
Outcomes
Long term
Outcomes
Goal
Overall goal: to reduce the likelihood of surgical patients developing
surgical site infections
RESOURCES
• Personnel:
• Trained in epidemiology and surveillance
• Clerical support
• Computer and information technology support
• Resources
Appropriate training for personnel responsible for
surveillance and/or data collection
ACTIVITIES
• Surveillance
• Communication of surveillance results
• Outcome monitoring
Activities
OUTPUTS
1. Regular report of procedure specific infection rates
and surveillance data to key stakeholders
2. Regular individual reports of surveillance data to
individual surgeons
3. Annual summary Short
report
from IPAC including total
term
number of surgicalOutcomes
patient developing SSIs, clinical,
Outputs
epidemiologic and/ microbiologic
features of patients
who have developed SSIs (made available to HCWs
caring for these patients)
TRANSFER OF ACCOUNTABILITY
• If no one, including the ICPs use the surveillance data
to alter practice, one must conclude that their current
system is ineffective
• SSI surveillance programs cannot produce the intended
outcome of reducing the likelihood of patient
developing an SSI unless members of the surgical
program take appropriate action
INTERMEDIATE OUTCOMES
• Enhanced dissemination of SSI rates and surveillance
data
• Increase awareness and understanding the impact of
SSIs and the population at risk of developing SSIs
• Increased ability to investigate
cases, determine time
Intermediate
Outcomes
and space clustering, and generate
hypotheses about
risk factors
• Increase in active interventions to reduce SSIs
LONGTERM OUTCOMES
• Improved assessments of patients at risk of developing
SSIs.
• Increased ability to determine whether interventions to
prevent infection were instituted effectively
• Improved use of SSI rates to investigateLong
deviations
term
Outcomes
from baseline rates
• Increased ability to monitor SSI rates when procedures
change
OVERALL GOAL
• to reduce the likelihood of surgical patients developing
surgical site infections (SSIs)
DEVELOPING EVALUATION QUESTIONS AND
INDICATORS
• Evaluation questions were grouped into 4 categories based on
what parts of the program were being evaluated:
1.
2.
3.
4.
Resources
Relevance
Process
Effectiveness
• Indicators were defined for each of the 16 evaluation
questions
Resources
Relevance
What resources are required to support current SSI
surveillance programs?
Do the ICPs in the region utilize the same standard
definition for SSIs?
Number of personnel with CIC* designation and
responsible for SSI surveillance program
Number of FTE required to produce current program
outputs
Number of ICPs using CDC standard case definitions
for SSIs
Process
Effectiveness
Who is the SSI surveillance data communicated to?
Have active interventions or changes to patient care
practices to reduce the risk of SSI been implemented
as a result of the SSI surveillance data?
Percent of members of surgical team receiving SSI
surveillance data per facility
Number of facilities reporting active interventions based
on SSI data
Number rating impact of SSI rates on active
intervention as 3 or higher
DATA COLLECTION PROCEDURES
Group exercise with ICPs using NHSN educational material to review
examples of types of SSIs and utilization of the CDC standard case
definition
Survey for ICPs on planning of program, types of procedures
performed, data collected, surveillance actives, and communication
of results
Engagement survey for surgical program members
Review of SSI rates of each facility data submitted by ICPs
KEY RESULTS AND ANALYSIS
RESPONDENTS
• 5/5 lead ICPs
• 43 / estimated
120
• ~36%
KEY RESULTS
• Standard surveillance definitions were used (CDC)
• 4/5 facilities reported procedure specific rates
• Data collected for each SSI case was almost identical
• Surveillance processes varied (especially post
discharge)
• Limited transfer of accountability (?) or surveys too long
(?)
RATING THE IMPACT OF SSI RATES
• on patient care practice changes as 3 or higher
• 10/12 rated 3 or higher
• on active interventions to decrease endemic or base
line rates as 3 or higher
• 9/12 rated 3 or higher
• on the ability to assess the efficacy of infection
prevention and control interventions as 3 or higher
• 10/12 rated 3 or higher
REVIEW OF SSI RATES
• Unfortunately, accurate numerator (number of SSIs)
and denominator data were not readily available for
inclusion the in this evaluation.
• Due to insufficient data available to perform a statistical
analysis, it was not possible to evaluate whether or not
a relationship exists between implementation of an SSI
surveillance program, and a reduction in the likelihood
of SSI.
RECOMMENDATIONS
Resources
More formal training for ICPs
Relevance
Incorporate retrospective chart review
Don’t compare current rates across facilities
(too much variation in post discharge
surveillance)
RECOMMENDATIONS
Process
Investigate ways to increase effectiveness of
transfer of accountability to various surgical
teams
Effectiveness
Educate surgical team members
Discuss SSI rates at relevant committees
Annually review SSI data and rates
LIMITATIONS
• Small group – only 5 facilities being evaluated in the
region
• Self-selection bias
• Response bias
• Low Response Rate – estimated 36%
• Drop out bias
NEXT STEPS
NEXT STEPS
• Facility ICPs provided with summary report
• Report recommendations considered per facility ICP /
Surgical Program
• Decision to establish regional bench mark for SSI
identified via readmission for the following procedures
• Primary total hip joint replacements
• Primary total knee joint replacements
• C-Sections
• Hysterectomies
QUESTIONS / COMMENTS
REFERENCES
•
Centers for Disease Control and Prevention (2011). Introduction to program evaluation for public health programs: A self-study guide. U.S. Department of Health
and Human Services Centers for Disease Control and Prevention. Office of the Director, Office of Strategy and Innovation, Atlanta, GA. Retrieved October 16 th,
2013 from: http://www.cdc.gov/EVAL/guide/CDCEvalManual.pdf
•
Society for Healthcare Epidemiologists of America (2004).Practical Handbook for Healthcare Epidemiologists 2 nd Edition. New Jersey, USA, SLACK Incorporated.
•
Zimlichman, E., Henderson, D., Tamir, O., Francz, C., Song, P., Yamin, C.K., Keohane, C., Denham, C.R., and Bates, D. W. (2013). Health Care-Associated
Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Internal Medicine, 173(22):2039-46.
•
Shojania, K., Duncan, B., McDonnald K., and Wachter, R. (2001). Making Health Care Safer: A critical Analysis of Patient Safety Practices - Evidence
Report/Technology Assessment. Agency for Healthcare Research and Quality; 2001:221-44. Retrieved March 12 th, 2014 from:
http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html
•
Kirkland, K., Briggs, J., Trivette, S., Wilkinson, W., and Sexton, D. (1999). The impact of surgical-site infections in the 1990s: Attributable mortality, excess length
of hospitalization, and extra costs. Infection Control and Hospital Epidemiology. 20(11): 725-730. Retrieved November 22 nd, 2014:
http://www.ansell.com/sites/corporate/files/content/brands/The%20Impact%20of%20Surgical%20Site%20Infections%20in%20the%201990s_Kirkland_1999.pdf
•
Provincial Infectious Disease Advisory Committee (2011). Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident
Populations. Ontario Agency for Health Protection and Promotion, Public Health Ontario. Retrieved January 28 th, 2014 from:
http://www.publichealthontario.ca/en/eRepository/Surveillance_3-3_ENGLISH_2011-10-28%20FINAL.pdf
•
Provincial Infectious Disease Advisory Committee (2011). Best Practices for Infection Prevention and Control Programs in Ontario. Ontario Agency for Health
Protection and Promotion, Public Health Ontario. Retrieved January 28 th, 2014 from:
http://www.publichealthontario.ca/en/eRepository/BP_IPAC_Ontario_HCSettings_2012.pdf
•
Lee, T., Montgomery, O., Marx, J., Olmsted, R., and Scheckler, W. (2007).Recommended practices for surveillance: Association for Professionals in Infection
Control and Epidemiology (APIC), Inc. American Journal of Infection Control J Infect Control , Volume 35:427-40. Retrieved November 11 th, 2013 from:
http://www.apic.org/Resource_/TinyMceFileManager/Practice_Guidance/AJIC-Surveillance-2007.pdf
•
Safer Healthcare Now! (2011). Prevent Surgical Site Infections – Getting Started Kit. Retrieved October 28 th, 2014 from:
http://www.saferhealthcarenow.ca/EN/Interventions/SSI/Documents/SSI%20Getting%20Started%20Kit.pdf
•
Nichols, R. (2001). Preventing Surgical Site Infections: A Surgeon’s Perspective. Emerging Infectious Diseases; 7(2): 220-224. Retrieved November 11 th, 2013
from: http://wwwnc.cdc.gov/eid/article/7/2/70-0220_article.htm
•
Centers for Disease Control and Prevention (2006). Outline for Healthcare-Associated Infections Surveillance. Department of Health and Human Services.
Retrieved November 5 th, 2013 from: http://www.cdc.gov/nhsn/pdfs/outlineforHAIsurveillance.pdf
•
Centers for Disease Control and Prevention (2012). Protocol for reporting Surgical Site Infections to the National Healthcare Safety Network (in use during 2011).
Retrieved October 12 th, 2014 from: http://www.cdc.gov/hai/pdfs/NHSN/9pscSSI-SAMPLE.pdf
•
Horan, T., Andrus, M, and Dudeck, M. (2008). CDC/NHSN surveillance definition of health-care associated infection and criteria for specific types of infections in
the acute care setting. American Journal of Infection Control. 36:309-32. Retrieved October 12 th, 2014 from: http://ac.els-cdn.com/S0196655308001673/1-s2.0S0196655308001673-main.pdf?_tid=7533c6fa-a9f7-11e3-b778-00000aacb35d&acdnat=1394636784_9a9aa7ac0f35b9ba273ffb1efb39009a
•
Mu, Y., Edwards, J., Horan, T., Berrios-Torres, S., and Fridkin, S. (2011). Improving Risk-Adjusted Measures of Surgical Site Infection for the National Healthcare Safety Network.
Infection Control and Hospital Epidemiology; 32(10) :970-986. Retrieved November 12 th, 2014 from: http://www.cdc.gov/nhsn/PDFs/pscManual/SSI_ModelPaper.pdf
•
Edwards, J., Peterson, K., Mu, Y., Banerjee, S., Allen-Bridson, K., Morrell, G., Dudeck, M., Pollock, D., Horan, T. (2009). National Healthcare Safety Network (NHSN) report: data
summary for 2006 through 2008. American Journal of Infection Control;37:783-805. Retrieved October 28 th, 2013 from:
http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.PDF
•
Victorian Nosocomial Infection Surveillance System (2013). VICNISS Surveillance Module: Surgical Site Infection (SSI) Protocol. Quality, Safety and Patient Experience Branch,
Victorian Government, Department of Health, Melbourne, Victoria. Retrieved October 6 th, 2013 from:
http://www.vicniss.org.au/Resources/HCWType1&2Manual/VICNISS_Surveillance_Type1&2_ModuleSSI_1Protocol.pdf
•
Victorian Nosocomial Infection Surveillance System (2013). VICNISS hospital acquired infection surveillance Annual Report 2009–10. Quality, Safety and Patient Experience
Branch, Victorian Government, Department of Health, Melbourne, Victoria. Retrieved October 6 th, 2013 from:http://www.vicniss.org.au/Resources/VICNISSAnnualReport2009-10.pdf
•
Center for Healthcare Related Infection Surveillance and Prevention (2008). Surgical Site Infection Signal - Section 4. Queensland Health. Retrieved November 12 th, 2014 from:
http://www.health.qld.gov.au/chrisp/signal_infection/signal-manual.pdf
•
European Centre for Disease Prevention and Control (2013). Long-term surveillance strategy 2014–2020. Stockholm: ECDC; 2013. Retrieved November 1 st, 2013 from:
http://www.ecdc.europa.eu/en/publications/publications/long-term-surveillance-strategy-2014-2020.pdf
•
European Centers for Disease Prevention and Control (2012).Surveillance of surgical site infections in European hospitals –HAISSI protocol. Version 1.02, Stockholm: ECDC.
Retrieved from: http://www.ecdc.europa.eu/en/publications/publications/120215_ted_ssi_protocol.pdf
•
European Centers for Disease Prevention and Control (2012). Surveillance of surgical site infections in European hospitals – HAISSI protocol. Version 1.02, Stockholm: ECDC.
Retrieved from: http://www.ecdc.europa.eu/en/publications/publications/120215_ted_ssi_protocol.pdf
•
Harrington, P., Wloch,C., Elgohari, S. and andLamagni, T. (2013). Protocol for the Surveillance of Surgical Site Infection. Public Health England -Surgical Site Infection Surveillance
Service. Retrieved November 12 th, 2014 from: http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1194947388966
•
Center for Health Protection (2009). Recommendations on Prevention of Surgical Site Infection. Scientific Committee on Infection Control, and Infection Control Branch, Centre for
Health Protection, Department of Health. Retrieved October 6 th, 2013 from:http://www.chp.gov.hk/files/pdf/recommendations_on_prevention_of_surgical_site_infection_r.pdf
•
National Collaborating Centre for Women’s and Children’s Health (2008). Surgical site infection prevention and treatment of surgical site infection - Clinical Guideline. Royal College
of Obstetricians and Gynaecologists. Retrieved February 13 th, 2014 from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0010039/
•
Provincial Infection Control Network (PICNet) (2008).Surgical Site Infection Surveillance Working Group’s Strategic Plan and Options Paper Report. Retrieved October 12 th, 2014
from: http://www.picnet.ca/download.php?filepath=%2Fpublications%2F21%2Fattachment.pdf&filetitle=SSI_Working_group_options_paper&extension=pdf
•
Centers for Disease Control and Prevention (2013). Surgical, Site, Infections (SSI) Case Studies. Retrieved December 8 th, 2013 from: http://www.youtube.com/watch?v=b6bdbjiZgiI
•
Altman, D. G. (1991). Practical statistics for medical research. London: Chapman & Hall/CRC.
•
Brenner, E. (2008). Explaining 95% Confidence Intervals. Retrieved March 28 th, 2014 from: https://mail.google.com/mail/?hl=en&shva=1#inbox/1453ed442a14e899