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.

SSI: I hear the words, SSI: I hear the words, but are we talking about the same thing?but are we talking about the same thing?

Safer Healthcare Now! Western Node

Wendy Runge, RN, BScN, CICWendy Runge, RN, BScN, CIC

Infection Prevention and Control, Infection Prevention and Control,

Calgary Health RegionCalgary Health Region

Surgical Site Infections: Simply Complicated

The SSI phenomena: The SSI phenomena: A simply complex problemA simply complex problem

Defining SSI:Defining SSI:Getting on the same Getting on the same

pagepage

CDC/NNIS SYSTEMCDC/NNIS SYSTEM

Guideline for Prevention of Guideline for Prevention of Surgical Site Infection, 1999 Surgical Site Infection, 1999 includes:includes:– Definition criteria for inclusion Definition criteria for inclusion

(or not!)(or not!)– Classification of infection Classification of infection

depthdepth

SSI depthSSI depth

CDC/NNIS SSI CDC/NNIS SSI CLASSIFACATION CLASSIFACATION SYSTEMSYSTEM

SSI DefinitionsSSI Definitions

Each depth has a set of Each depth has a set of definition criteriadefinition criteria

Each case must meet the Each case must meet the definition criteria definition criteria EXACTLYEXACTLY

Extended surveillance period for Extended surveillance period for implant surgery (12 months)implant surgery (12 months)

CDC/NNIS SYSTEMCDC/NNIS SYSTEM

NNIS reports:NNIS reports:– Criteria for risk stratificationCriteria for risk stratification– Provides risk adjusted Provides risk adjusted

‘Benchmark’ rates for specific ‘Benchmark’ rates for specific proceduresprocedures

NNIS RatesNNIS Rates

Risk- adjusted NISS ‘Benchmark’ Risk- adjusted NISS ‘Benchmark’ infection rate for hip prosthesis:infection rate for hip prosthesis:

0 = 0.54%0 = 0.54%

1 = 1.24%1 = 1.24%

2, 3 = 2.05%2, 3 = 2.05%

(50(50thth percentile rates; taken from the percentile rates; taken from the 1992-2003 NNIS report)1992-2003 NNIS report)

It all started here…It all started here…

Case Study: Mrs. DCase Study: Mrs. D

73 year old female with IDDM, CAD, 73 year old female with IDDM, CAD, COPD and osteoarthritisCOPD and osteoarthritis

Right total hip performed in Right total hip performed in March/2005March/2005

Operative Details:Operative Details:– Intra operative cultures negIntra operative cultures neg– Procedure took 2:30Procedure took 2:30– PatientPatient ASA score was ‘3’ ASA score was ‘3’

– Wound classification = CleanWound classification = Clean

Case Study: Mrs. DCase Study: Mrs. D

Is Mrs. D a high surgical risk Is Mrs. D a high surgical risk patient?patient?

What is her NNIS risk score?What is her NNIS risk score?

Mrs. D Mrs. D (cont.)(cont.)

Uneventful surgery and hospital Uneventful surgery and hospital recovery, with discharge on day recovery, with discharge on day 66

Wound was ‘well approximated’ Wound was ‘well approximated’ with ‘scant serous discharge’with ‘scant serous discharge’

Does the drainage indicate an Does the drainage indicate an infection?infection?


At 14 days post op, Mrs. D At 14 days post op, Mrs. D presents to ER with R hip redness presents to ER with R hip redness and some localized edemaand some localized edema

No drainage noted, no culturesNo drainage noted, no cultures The ER doc diagnoses ‘Cellulitis’ The ER doc diagnoses ‘Cellulitis’

and starts her on a course of and starts her on a course of KeflexKeflex

Is this an infection? Is this an infection?


4 weeks post op, Mrs. D presents 4 weeks post op, Mrs. D presents in ER again, this time with hip in ER again, this time with hip pain, fever and an elevated WBCpain, fever and an elevated WBC

She is admitted to hospital with She is admitted to hospital with the diagnosis “Query septic joint”the diagnosis “Query septic joint”

Joint aspirate cultures are Joint aspirate cultures are negativenegative

Is this an infection?Is this an infection?


Mrs. D’s urine cultures grow Mrs. D’s urine cultures grow Pseudomonas aeruginosaPseudomonas aeruginosa

Right hip xrays report no Right hip xrays report no significant findingssignificant findings

Her UTI is treated and she is Her UTI is treated and she is dischargeddischarged


3 months post op, Mrs. D again 3 months post op, Mrs. D again presents with hip pain, fever and presents with hip pain, fever and an elevated WBCan elevated WBC

R hip Xray reports areas of R hip Xray reports areas of lucidity and possible loosening lucidity and possible loosening of the prosthesisof the prosthesis


Mrs. D Mrs. D (cont.)(cont.) Urine culture is negative, CXR Urine culture is negative, CXR

shows no acute changesshows no acute changes CT scan of her R hip reports a fluid CT scan of her R hip reports a fluid

collection in the subcuticular tissuecollection in the subcuticular tissue The collection is aspirated:The collection is aspirated:

– Straw-colored fluidStraw-colored fluid– Cultures = ‘no growth’Cultures = ‘no growth’



Joint aspirate grew Joint aspirate grew Coagulase Coagulase negative staphylococcusnegative 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’



Surgical Procedure: Evacuation Surgical Procedure: Evacuation of seroma, debridement and of seroma, debridement and liner exchange R hipliner exchange R hip

Surgeon’s Operative report: Surgeon’s Operative report: Evacuation of Seroma, Evacuation of Seroma, devitalized tissue debrided, joint devitalized tissue debrided, joint irrigated and liner exchanged irrigated and liner exchanged (no pus seen)(no pus seen)


2:4 intraoperative tissue 2:4 intraoperative tissue cultures grow cultures grow Coagulase Coagulase negative staphylococcusnegative staphylococcus

A PICC is inserted course of A PICC is inserted course of Vancomycin is startedVancomycin is started

Is this an infection?Is this an infection? If yes, then what depth?If yes, then what depth?


What are some possible reasons What are some possible reasons that Mrs. D developed a surgical that Mrs. D developed a surgical site infection?site infection?

What is the probable source of What is the probable source of the infection?the infection?


Possible outcomes:Possible outcomes:– Cure – no further problemsCure – no further problems– Premature loosening and early Premature loosening and early

revisionrevision– Excision arthroplasty with 2-Excision arthroplasty with 2-

stage revisionstage revision

SurveillanceSurveillance

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 SpecialistBC Provincial Infection Control Network

Process of SurveillanceProcess of Surveillance

Determine an ObjectiveDetermine an Objective Identify variations in the rate within a Identify variations in the rate within a

clinically relevant time frame clinically relevant time frame


Define the EventDefine the Event NNIS - superficial, deep, organ space NNIS - superficial, deep, organ space


Identify the data sources, who Identify the data sources, who collects the data, how frequently, collects the data, how frequently, triggers and timing triggers and timing

Process SurveillanceProcess Surveillance

Data collection form Data collection form Numerator Numerator DenominatorDenominator


Analyze, interpret, disseminate the Analyze, interpret, disseminate the information information

DiscussionDiscussion

Table discussion on how surveillance Table discussion on how surveillance is viewed at each team levelis viewed at each team level

Report outReport out

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.

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