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An Evaluation of Surgical Site Infection Surveillance Methods for Colon Surgery and Hysterectomy in Colorado Hospitals

Published online by Cambridge University Press:  29 December 2014

Sara M. Reese,
Bryan C. Knepper,
Connie S. Price and
Heather L. Young
Sara M. Reese*
Affiliation:
Department of Patient Safety and Quality, Denver Health Medical Center, Denver, Colorado
Bryan C. Knepper
Affiliation:
Department of Patient Safety and Quality, Denver Health Medical Center, Denver, Colorado
Connie S. Price
Affiliation:
Division of Infectious Diseases, Denver Health Medical Center and University of Colorado, Denver, Colorado.
Heather L. Young
Affiliation:
Division of Infectious Diseases, Denver Health Medical Center and University of Colorado, Denver, Colorado.
*
Address correspondence to Sara M. Reese, PhD, CIC, Denver Health Administration, 660 Bannock St., MC 0980, Denver, CO 80204 (sara.reese@dhha.org).
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Abstract

Surgical site infection (SSI) surveillance techniques for colon surgery and hysterectomy among Colorado infection preventionists were characterized through an online survey. Considerable variation was found in SSI surveillance practices, specifically varying use of triggers for SSI review, including laboratory values, healthcare personnel communication, and postoperative visits.

Infect Control Hosp Epidemiol 2014;00(0): 1–3

Information

Type
Concise Communications
Information
Infection Control & Hospital Epidemiology , Volume 36 , Issue 3 , March 2015, pp. 353 - 355
Copyright
© 2014 by The Society for Healthcare Epidemiology of America 

Surgical site infection (SSI) rates are collected by both local and national organizations. In 2006, Colorado began publicly reporting rates of SSI for select procedures.1 In addition, the Centers for Medicare and Medicaid Services require all hospitals to report SSI rates for colon surgery and hysterectomy; reimbursement will be partially based on these rates beginning in January 2016.Reference Stone, Glied and McNair2

Despite emphasis on SSI for public reports and Centers for Medicare and Medicaid Services reimbursements, little is known about techniques that infection preventionists (IP) use for SSI surveillance. Because of competing priorities, IP often cannot review every patient’s medical chart postoperatively to assess for SSI; triggers are typically used to prioritize specific high-risk charts for review. These triggers may include International Classification of Diseases, Ninth Revision codes, wound culture results, hospital readmissions or repeat surgeries, inpatient antibiotics, or communication with a surgeon, hospital staff, or patients.Reference Yokoe, Noskin and Cunnigham3–Reference Miner, Sands and Yokoe5

The purpose of this study was to characterize SSI surveillance techniques for colon surgery and hysterectomy amongst Colorado IP.

METHODS

Study Design and Population

A 15-question anonymous online survey was created to characterize SSI surveillance techniques used by IP for colon surgery and hysterectomy. A focus group of 3 IP with varying backgrounds provided feedback on survey questions. The study population included IP from all acute care hospitals in Colorado that performed 20 colon surgeries or hysterectomies from August 1, 2012, through July 31, 2013. IP at hospitals with low surgical volume (ie, <20 surgeries or hysterectomies) were excluded. IP were identified through the local Association of Professionals in Infection Control and Epidemiology chapter and a supplemental list obtained from Colorado Department of Public Health and Environment. A survey link was distributed via email; a reminder email was sent 2 weeks after initial mailing.

Evaluation of SSI Surveillance Technique

Survey questions addressed the percentage of charts reviewed, time dedicated to SSI surveillance each month, and methods used to trigger medical chart review, including laboratory tests, communication with healthcare personnel (HCP), and postoperative visits (ie, surgeon office, emergency room, and operating room). IP who used at least 2 laboratory tests, communicated with at least 2 HCP, or used at least 3 postoperative visits were deemed to be using vigorous SSI surveillance techniques for the purposes of the combination analysis.

Statistical Analysis

Descriptive statistics were used to characterize SSI surveillance techniques. The χ2 and Mantel-Haenszel tests were used to determine relationships between variables. All analyses were performed using SAS, version 9.2 (SAS Institute). The Colorado Multiple Institutions Review Board approved this study.

RESULTS

Survey Responses

The survey link was distributed to IP in all acute care hospitals in Colorado. Survey responses were obtained from IP at 26 of 38 hospitals (68%) that performed at least 20 colon surgeries and 29 of 46 (63%) that performed at least 20 hysterectomies. Survey responses from IP at 6 hospitals that performed fewer than 20 colon surgeries or hysterectomies were excluded.

General Information

IP varied in the percentage of charts reviewed and number of hours dedicated per month to colon surgery and hysterectomy SSI surveillance. There was a nonsignificant trend toward hospitals with larger surgical volume reviewing a smaller percentage of charts and spending more cumulative time per month on SSI surveillance.

Laboratory Tests

Of the 30 IP, 29 (97%) used positive wound culture results to trigger medical chart review; less than half used negative wound culture results. Leukocytosis was used by 4 (13%) and C-reactive protein was used by 1 (3%). One IP used none of these laboratory tests in surveillance and 15 (50%) used only 1 laboratory test (Figure 1). Fourteen IP (47%) used at least 2 laboratory tests for SSI surveillance and were included in the combination analysis.

FIGURE 1

Triggers for review of medical charts for surgical site infection surveillance. Infection preventionists use a varying number of laboratory tests, healthcare personnel (HCP) communication, and postoperative visits to trigger medical chart review for surgical site infection surveillance. A varying percentage of infection preventionists use no, one, or multiple methods (demonstrated by the combination of methods).

HCP Communication

For SSI surveillance, 25 IP (83%) communicated with the surgeon, 12 (40%) with the infectious disease physician, 7 (23%) with the wound care nurse, 6 (20%) with the emergency department/urgent care personnel, and 5 (17%) with the infusion center staff. Two IP communicated with no HCP and 15 (50%) communicated with 1 HCP as a means of SSI surveillance (Figure 1). Thirteen IP (43%) communicated with at least 2 HCP for SSI surveillance and were included in the combination analysis.

Postoperative Visits

Locations for postoperative visits that were tracked by IP included operating room (20 [67%]), emergency department/urgent care (19 [63%]), surgeon office (11 [37%]), wound care clinic (9 [30%]), primary care physician office (7 [23%]), infusion center (5 [17%]), and hospital readmissions (3 [10%]). Six IP (20%) did not use postoperative visits to identify patients at risk for SSI; 4 IP (13%) used 1 and 2 IP (7%) used 2 types of postoperative visits (Figure 1). Eighteen IP (60%) used at least 3 postoperative visits for SSI surveillance and were included in the combination analysis.

Combination Analysis

The number of SSI surveillance methods used by IP varied (Figure 1). IP at hospitals performing more than 200 colon surgeries and hysterectomies combined per year tended to use at least 2 methods more often than IP at hospitals that performed fewer than 200 colon surgeries and hysterectomies combined per year (67% vs 33%, P=.26).

DISCUSSION

This study found considerable variation in the SSI surveillance practices of Colorado IP. Specifically, IP dedicate different amount of time, review varying percentages of medical charts, and use varying triggers for detection of colon surgery and hysterectomy SSI.

Substantial time and resources are required to maintain a rigorous SSI surveillance program. Evidence suggests that high-quality postdischarge surveillance will result in an increase in SSI detection compared with low-quality SSI surveillance.Reference Yokoe, Noskin and Cunnigham3, Reference Tanner, Padley, Kiernan, Leaper, Norrie and Baggott6 Tanner et alReference Tanner, Padley, Kiernan, Leaper, Norrie and Baggott6 reported a 2.5 times higher SSI rate after knee arthroplasty in facilities that performed high-quality postdischarge surveillance. Ming et alReference Ming, Chen, Miller and Anderson7 reported that inconsistent surveillance methods significantly affect SSI rates and publicly available hospital performance rankings. The variation in time dedicated, percentage of medical charts reviewed, and surveillance methods observed in this study suggests that publicly reported SSI data may not be comparable between facilities.

The differences in SSI surveillance techniques found in this study are consistent with the literature; to our knowledge there are no previously reported standard SSI surveillance methods.Reference Yokoe, Noskin and Cunnigham3, Reference Miner, Sands and Yokoe5, Reference Anderson, Podgorny and Berrios-Torres8

There are practical reasons why IP use different SSI surveillance techniques. Although microbiology culture results were consistently used to identify medical charts for review, postdischarge surveillance was variable. IP access to outpatient visits depends upon integration between inpatient and outpatient medical records. With 60% to 80% of SSI occurring after hospital discharge,Reference Oliveira and Carvalho9, Reference Prospero, Cavicchi, Bacelli, Barbadoro, Tantucci and D'Errico10 SSI detection could be drastically lower for IP without access to outpatient records.

Strengths of this study include participation of IP at hospitals from a variety of settings. Additionally, Colorado has been publicly reporting SSI rates since 2007; therefore, IP have established methods of SSI surveillance. This study may have been subject to participation bias with those IP who are interested in the topic being more likely to participate.

In conclusion, there are significant variations in SSI surveillance methods performed by IP in Colorado hospitals for publicly reported surgeries. Infection rates for colon surgery and hysterectomy are being used for both public hospital comparisons and Centers for Medicare and Medicaid Services reimbursement.Reference Stone, Glied and McNair2 The effect of SSI surveillance methods on reported SSI rate should be further studied to ensure that public reporting and Centers for Medicare and Medicaid Services reimbursement are equitable.

Acknowledgments

We thank the IP and hospital personnel in Colorado who participated in the study. We thank members of the Mile Chapter of the Association of Professionals in Infection Control and Epidemiology; Tara Janosz, MPH, infection preventionist at University of Colorado Hospital; and Heather Gilmartin, PhD, NP, CIC, public health nurse at Eagle County Public Health Department, for their comments and suggestions regarding the survey content and flow.

Financial support. None reported.

Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.

References

REFERENCES

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Figure 0

FIGURE 1Triggers for review of medical charts for surgical site infection surveillance. Infection preventionists use a varying number of laboratory tests, healthcare personnel (HCP) communication, and postoperative visits to trigger medical chart review for surgical site infection surveillance. A varying percentage of infection preventionists use no, one, or multiple methods (demonstrated by the combination of methods).