To the Editor—Surveillance, “the ongoing, systematic collection, analysis, and interpretation of health-related data essential to planning, implementation, and evaluation of public health practice,”1 is a pillar of healthcare infection control.Reference Haley, Culver and White2 The highly regarded and very effective National Healthcare Safety Network (NHSN) of the Centers for Disease Prevention and Control (CDC) has surveillance definitions and criteria for many specific types of healthcare-associated infections that provide important and actionable information for the CDC’s practice-guiding and standard-setting infection control recommendations.
For individual hospitals or healthcare systems, the general goals of their infection surveillance activities include (1) using NHSN definitions for accurately identifying healthcare-associated infections or other problem areas, particularly those that would require and potentially benefit from intervention; (2) carefully measuring success of control measures; and (3) in some instances, meeting public reporting requirements and guiding pay-for-performance programs. All of these goals have been established in the spirit of “what is measured improves.”Reference Weinstein and Jameson3
A report in this issue by Seidelman and her Duke University Medical Center colleagues raises questions about the omission in some nosocomial surveillance systems (and from some hospital quality assessment criteria) of superficial incisional surgical site infections.Reference Seidelman, Smith and Shoff4 The report proposes a refinement for surgical site infection (SSI) surveillance, specifically aimed at evaluating the potential morbidity of what they term serious superficial incisional SSIs (SSISSIs). The authors define an SSISSI as a superficial incisional SSI that (1) required debridement in an OR and/or (2) led to a hospital readmission within 30 days of surgery. To assess the potential problems caused by SSISSIs, they reviewed a cohort of almost 42,000 operations performed during 4 years (2013–2017) at 3 Duke-affiliated hospitals. This cohort included adult patients who had undergone 1 of 7 “clean” procedures: craniotomy, spinal fusion, laminectomy, hip arthroplasty, knee arthroplasty, mastectomy, or cardiac bypass surgery.
The overall SSI rate in this surgical cohort was 1.1%. Of almost 500 SSIs, infection prevention personnel classified 89 (19%) as superficial, of which 67 (75%) met the SSISSI definition. In their study, the overall risk for detected SSISSIs was very small (ie, 67 events in ~42,000 operations over almost 4 years), but the morbidity in this subset was substantial (eg, a 9-day average length of stay for the readmitted patients) and the primarily culture-based surveillance and stringent SSISSI criteria may have undercounted these infections.
The Duke group has previously raised questions about NHSN surveillance definitions and reporting for vascular catheter-related bloodstream and urinary catheter-related infections.Reference Sexton, Chen and Anderson5, Reference Anderson, Freeman and Sexton6 The present study adds another innovative assessment and provocative boundary-pushing question to their pursuit of what to include in routine acute-care infection control surveillance.
In light of the general goals of healthcare infection surveillance for hospitals, what would be the potential benefits of this proposed SSI surveillance refinement? Would we find systemic problems leading to SSISSIs that could be corrected and from which patient care would benefit? Would additional surgeons, beyond those identified by current surveillance activities, be identified who would benefit from a systematic review of their practices and SSISSI risk? Would we identify other quality issues that might inform prevention, reporting, and institutional ratings? And what are the economics (ie, the cost–benefit) of this addition to routine surveillance?
The current study does not answer these questions, but it raises enough interest in the problem of SSISSIs that we should investigate them. So, what are the next steps? I agree with the authors that the importance and the value of SSISSI surveillance need to be studied in other healthcare systems to determine whether the Duke findings can be reproduced and the extent to which these findings are generalizable. Most importantly, is this surveillance useful for judging and improving the quality of surgical care for our patients? If so, can logistics for effective surveillance, reporting, and responding to SSISSIs be developed?
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To the Editor—Surveillance, “the ongoing, systematic collection, analysis, and interpretation of health-related data essential to planning, implementation, and evaluation of public health practice,”1 is a pillar of healthcare infection control.Reference Haley, Culver and White2 The highly regarded and very effective National Healthcare Safety Network (NHSN) of the Centers for Disease Prevention and Control (CDC) has surveillance definitions and criteria for many specific types of healthcare-associated infections that provide important and actionable information for the CDC’s practice-guiding and standard-setting infection control recommendations.
For individual hospitals or healthcare systems, the general goals of their infection surveillance activities include (1) using NHSN definitions for accurately identifying healthcare-associated infections or other problem areas, particularly those that would require and potentially benefit from intervention; (2) carefully measuring success of control measures; and (3) in some instances, meeting public reporting requirements and guiding pay-for-performance programs. All of these goals have been established in the spirit of “what is measured improves.”Reference Weinstein and Jameson3
A report in this issue by Seidelman and her Duke University Medical Center colleagues raises questions about the omission in some nosocomial surveillance systems (and from some hospital quality assessment criteria) of superficial incisional surgical site infections.Reference Seidelman, Smith and Shoff4 The report proposes a refinement for surgical site infection (SSI) surveillance, specifically aimed at evaluating the potential morbidity of what they term serious superficial incisional SSIs (SSISSIs). The authors define an SSISSI as a superficial incisional SSI that (1) required debridement in an OR and/or (2) led to a hospital readmission within 30 days of surgery. To assess the potential problems caused by SSISSIs, they reviewed a cohort of almost 42,000 operations performed during 4 years (2013–2017) at 3 Duke-affiliated hospitals. This cohort included adult patients who had undergone 1 of 7 “clean” procedures: craniotomy, spinal fusion, laminectomy, hip arthroplasty, knee arthroplasty, mastectomy, or cardiac bypass surgery.
The overall SSI rate in this surgical cohort was 1.1%. Of almost 500 SSIs, infection prevention personnel classified 89 (19%) as superficial, of which 67 (75%) met the SSISSI definition. In their study, the overall risk for detected SSISSIs was very small (ie, 67 events in ~42,000 operations over almost 4 years), but the morbidity in this subset was substantial (eg, a 9-day average length of stay for the readmitted patients) and the primarily culture-based surveillance and stringent SSISSI criteria may have undercounted these infections.
The Duke group has previously raised questions about NHSN surveillance definitions and reporting for vascular catheter-related bloodstream and urinary catheter-related infections.Reference Sexton, Chen and Anderson5, Reference Anderson, Freeman and Sexton6 The present study adds another innovative assessment and provocative boundary-pushing question to their pursuit of what to include in routine acute-care infection control surveillance.
In light of the general goals of healthcare infection surveillance for hospitals, what would be the potential benefits of this proposed SSI surveillance refinement? Would we find systemic problems leading to SSISSIs that could be corrected and from which patient care would benefit? Would additional surgeons, beyond those identified by current surveillance activities, be identified who would benefit from a systematic review of their practices and SSISSI risk? Would we identify other quality issues that might inform prevention, reporting, and institutional ratings? And what are the economics (ie, the cost–benefit) of this addition to routine surveillance?
The current study does not answer these questions, but it raises enough interest in the problem of SSISSIs that we should investigate them. So, what are the next steps? I agree with the authors that the importance and the value of SSISSI surveillance need to be studied in other healthcare systems to determine whether the Duke findings can be reproduced and the extent to which these findings are generalizable. Most importantly, is this surveillance useful for judging and improving the quality of surgical care for our patients? If so, can logistics for effective surveillance, reporting, and responding to SSISSIs be developed?
Acknowledgments
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Conflicts of interest
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