Surveillance of Caesarean Section Surgical Site Infection in Ireland

Transcription

1 Surveillance of Caesarean Section Surgical Site Infection in Ireland Protocol Surveillance Manual Version 1 January 2009 Health Protection Surveillance Centre

2 Acknowledgements This protocol has been adapted from the Panceltic Surveillance Network protocol for caesarean section surgical site infection surveillance. We gratefully acknowledge the support and assistance of the following: Ms. Anne Marie Meenan, Professor Michael Turner, and Dr. Christopher Fitzpatrick, Coombe Women and Infants University Hospital, Dublin Dr. Edward TM Smyth, Mr. Gerard McIlvenny and Ms. Geraldine Reid, rthern Ireland Healthcare-associated Infection Surveillance Centre Ms. Abigail Mullings, Consultant Nurse Epidemiologist, Health Protection Scotland The Panceltic Surveillance Network Health Protection Surveillance Centre 1

3 General Enquires and Contact Details If you have any difficulties or queries with the definitions in this manual or feedback with any aspect of this manual please contact a member of the HPSC surveillance team: Organisation, questionnaires & results: fionamary.roche@hse.ie Other queries: Sheiladonlon1@hse.ie fidelma.fitzpatrick@hse.ie HPSC Mailing address: HSE - Health Protection Surveillance Centre, Middle Gardiner Street, Dublin 1, Ireland Tel: Fax: Health Protection Surveillance Centre 2

4 Contents SECTION 1 4 Introduction and Methodology Introduction Aims of surgical site infection surveillance Surveillance methods 7 SECTION 2 9 Surveillance Form 9 Fields and Definitions Sample surveillance form Panceltic SSI Core Dataset Caesarean Section Additional n-core Data How to fill-in survey forms Care of survey forms Definitions and reporting instructions 16 Reporting Instructions: 16 Definitions (core data set variables marked with * prefix): 17 Hospital Details (Questions 1 3): 17 Patient Details (Questions 4 5): 17 Height and Weight Measurements (Questions 6 9): 17 Clinical Details (Questions 10 15): 18 Procedure and Surgeon Details (Questions 15 23): 19 Anaesthesia and prophylactic antibiotics (Questions 24 28): 21 Operative Details (Questions 29 33): 21 Outcome (Questions 34 38): 22 Surgical site infection details (Questions 39 45): 23 SECTION 3 27 REFERENCES 27 REFERENCES 28 SECTION 4 29 APPENDICES 29 Appendix 4.1 Schematic of surveillance process 30 Appendix 4.2 Schematic of diagnosing surgical site infections 31 Health Protection Surveillance Centre 3

5 SECTION 1 Introduction and Methodology Health Protection Surveillance Centre 4

6 1.1 Introduction Surgical site infections are one of the most common health-care associated infections (HCAI). They represent a significant burden in terms of patient morbidity and mortality and can result in increases in length of hospital stay and costs of hospitalisation (1,2,3). The establishment of well-organised infection control surveillance programs have been shown in multiple studies to reduce rates of surgical site infection (4,5), thus representing one successful approach to tackle this problem. In May 2007, the SARI (Strategy for the control of Antimicrobial Resistance in Ireland) National Committee agreed that a subcommittee be established to produce recommendations on surveillance of surgical site infection in Ireland. This was subsequent to agreement at the Health Service Executive (HSE) healthcare-associated infections (HCAI) Governance Committee that HCAI surveillance was one of the key components in the prevention and control of HCAI. Members of the subcommittee included: Dr. Fidelma Fitzpatrick, Consultant Microbiologist, Health Protection Surveillance Centre (HPSC) & Beaumont Hospital, Dublin (Chair) Ms. Mary Kelleher, Surveillance Scientist, St. James s Hospital, Dublin (representing the Surveillance Scientists Association) Mr. Ken Mealy, Consultant Surgeon, Wexford General Hospital, Wexford (lead surgeon driving the General Surgery surveillance initiative in Wexford Hospital) Dr. Olive Murphy, Consultant Microbiologist, Bon Secours Cork (representing the Irish Society of Clinical Microbiologists - ISCM) Dr. Brian O Connell, Consultant Microbiologist, St. James s Hospital, Dublin (representing ISCM) Mr. Ajay Oza, Surveillance Scientist, HPSC. Dr. Fiona Roche, Surveillance Scientist, HPSC. Dr. Edward Smyth, Director, rthern Ireland Healthcare-associated infection Surveillance Centre and Consultant Microbiologist, Royal Hospitals, rthern Ireland. Ms. Mairead Twohig, Infection Control, Our Lady of Lourdes Hospital Drogheda. (representing the Infection Control Nurses Association) The committee first met on 30 th July Recommendations on the surveillance of surgical site infection (SSI), and a standardised national protocol containing a core dataset for general surgery were published in May 2008 and are available at: In light of surveillance initiatives in post caesarean section surgery across the country, the committee agreed to produce a similar, internationally comparable protocol for surveillance of surgical site infection post caesarean section. Ms. Anne Marie Meenan, Professor Michael Turner, and Dr. Christopher Fitzpatrick of the Coombe Women and Infants University Health Protection Surveillance Centre 5

7 Hospital, Dublin agreed to join the group and share their experiences of a pilot project performed in their institution, in order to inform development of this protocol. As with the general surgery protocol, in order to enable national and international comparisons, the CDC definitions of surgical site infection should be employed (13) when implementing caesarean section surgical site infection surveillance. As the collection of data for the surveillance of any type of surgical site infection involves a large number of staff including surgeons, nurses, infection prevention and control and administrative staff, it is recommended that institutions nominate a coordinator for surveillance from the outset to coordinate surveillance efforts. The purpose of this manual is to guide individual hospitals interested in participating in caesarean section SSI surveillance to use a standardised approach in data collection by providing information, definitions, and instructions. The core data set of questions are highlighted in both the proposed surveillance form and the definitions section of this document (denoted by the * prefix). These core questions have been defined by the Panceltic Surveillance Network. It is strongly advised that participants maintain core questions, and adhere to the CDC definitions, when implementing a surveillance initiative. This will ensure that not only is your data comparable both nationally but also internationally to countries participating in the Panceltic surveillance network. In addition, it will provide a benchmark allowing individual hospitals to compare their rates of caesarean section SSI over time. We have provided an example of a caesarean section surgery surveillance form containing all of the core dataset questions (marked with a * prefix), however institutions may wish to generate their own scannable forms and include additional questions as locally relevant. If there are existing IT systems within the hospital that could be employed for surveillance (e.g. use of surgical software systems for data entry such as CIS metavision), these could also be used for caesarean section SSI surveillance rather than scanning, where feasible. We hope that use of this protocol will ensure a standardised approach to data collection and enable comparative analysis of data at a national level. Institutions are requested not to alter the Panceltic core dataset as outlined in this manual. However as previously outlined, institutions may wish to add additional surveillance questions as locally relevant. It is hoped that the information contained in this manual is clear and concise and will assist you in the completion of the surveillance forms. Health Protection Surveillance Centre 6

8 1.2 Aims of surgical site infection surveillance The aim of a caesarean section SSI surveillance programme is to ensure standardisation of definitions, data collection and reporting procedures for all participating hospitals. To achieve this aim the main objectives of a caesarean section SSI programme should be: I. To collect surveillance data on the rates of SSI post caesarean section procedures to permit estimation of the magnitude of risks associated with the operation II. III. To analyse and report caesarean section SSI surveillance data and to provide riskadjusted rates of infection and associated trends To provide timely feedback on the rate of SSI associated with caesarean section procedures to assist units in minimising their occurrence. 1.3 Surveillance methods The surveillance method needed is prospective active surveillance. This means that designated and trained members of the surveillance team have to monitor each patient included in the surveillance program from the date of their procedure until they are discharged from hospital. It is important to note that the diagnosis of a caesarean section SSI is made by a surgeon or attending physician according to the CDC definitions. See Appendix 4.1 for a schematic flowchart of the different stages of setting up caesarean section SSI surveillance. Any patient who then undergoes a caesarean section surgical procedure, regardless of the presence of a SSI, should be included in the surveillance programme. All patients included in the surveillance should be followed up prospectively from the time of surgery to discharge. Ideally all patients should be enrolled in surveillance with a follow up period of 30 days post-operation (in accordance with CDC definitions). However the feasibility of such monitoring has not yet been established. While we realise that postdischarge surveillance is an extremely resource intensive process, in the event that the patient is re-admitted to your hospital with a caesarean section SSI, within this 30 day period, it is recommended that you continue surveillance on the patient. Each patient should have only one form per episode and in this event, the original form should be updated and completed appropriately. It is important to note that any surveillance system that does not incorporate both in-patient and post-discharge surveillance is incomplete. A two-page surveillance form representing the Panceltic core (marked with a * prefix) minimum dataset is provided within this document. This form is a sample form. It represents a template and can be used to guide hospitals in the design of their own forms/databases. Hospitals may wish to add additional questions to the core minimum dataset to address issues within their own institution. It is strongly recommended that forms be designed using form-recognition software so that data collected can be scanned directly into a database to Health Protection Surveillance Centre 7

9 increase efficiency and improve data quality. Also, field names of the core minimum dataset (marked with a * prefix) should not change to allow downstream data integration at a later stage. Hospitals without form-recognition software should contact the HPSC to discuss other possible options. Integral to the success of any surveillance system is interdisciplinary co-operation, with involvement of nursing, medical and administrative staff with the Infection Prevention and Control Team. It is crucial that this team is supported by the institutions management team. Health Protection Surveillance Centre 8

10 SECTION 2 Surveillance Form Fields and Definitions Health Protection Surveillance Centre 9

11 2.1 Sample surveillance form The surveillance form below is a composite of working surveillance forms provided by the Panceltic Surveillance Network and the Coombe Women and Infants University Hospital, Dublin. As already stated, Panceltic core data questions are denoted with the prefix *. For reasons previously discussed, when implementing this surveillance system it is strongly recommended that core data questions and CDC definitions of SSI are maintained. You may wish to change the format of this form or include additional questions as locally relevant. Health Protection Surveillance Centre 10

12 Page 1 of sample form Health Protection Surveillance Centre 11

13 Page 2 of sample form Health Protection Surveillance Centre 12

14 2.2 Panceltic SSI Core Dataset Caesarean Section Table 2.1 outlines the components of the Panceltic core data set for surgical site infection surveillance. Institutions may wish to add additional fields (see Table 2.2) as dictated by local requirements, however the core dataset and the exact core dataset field names should be collected as a minimum and should not be modified. Table 2.1 Panceltic Core Dataset Pre-Operative Data Peri-Operative Data Post-Operative Data Hospital code Surgery type Caesarean SSI Patient number Operating surgeon (intls) Date of discharge Consultant Initials Date of Birth Date of Procedure Grade of operator Date of surveillance discontinued Reason surveillance discontinued Date of Admission Procedure Date of SSI Height ASA classification When was SSI recorded Weight Wound class Infection type Anaesthesia Organ/space site affected Prophylactic antibiotics and timing Patient death Number of antibiotics Time of incision Time of closure Re-intervention required Re-intervention time of incision Re-intervention time of closure Health Protection Surveillance Centre 13

15 2.3 Additional n-core Data Additional, non core, data might also be collated at local levels (Table 2.2). Table 2.2 Optional fields to include in caesarean surgical site infection surveillance form Optional additional fields Description BMI Body Mass Index enter if available When was weight taken? Previous C/S(s) Gestation at caesarean section Intact membranes on admission? Hours membrane ruptured prior to delivery. Enter weeks gestation when weight was recorded. Select if patient had a previous section, otherwise select. Period in weeks/days of pregnancy If the foetal membranes were not ruptured when the patient was admitted to the hospital record, otherwise record ' Enter the number of hours membranes were ruptured prior to delivery Diabetes Control of diabetes Was patient on innohep prior to C/S? If a consultant did not perform the procedure was the surgeon supervised by a consultant? Antibiotic given Does patient have diabetes mellitus? If patient is diabetic enter if diabetes is controlled by tablet, insulin or is gestational. Select yes if the patient received innohep prior to the caesarean section. Select the antibiotics administered from the list Estimated blood loss Enter the estimated blood loss in mls Did the patient require re-admission? Follow up post discharge within 30 days Date of re-admission Why was patient re-admitted Were antibiotics prescribed for SSI? Complete date of re-admission State whether patient was re-admitted for C-SSI or for other reasons. State yes or no Was there a heamatomae in the SSI? State yes or no Health Protection Surveillance Centre 14

16 2.4 How to fill-in survey forms Surveillance forms should be generated using form-recognition software (such as Teleform or Formic) to ensure high quality and efficiency in data collection. For forms developed by such software, it is important to follow the points outlined below in filling in these forms to ensure a valid and accurate scanning process. Use a dark ink pen or biro. Avoid light coloured pens, e.g. green. Place cross (not tick) in appropriate box, i.e. Some questions can have more than one response. These are clearly indicated. Mistakes can be rectified. If an incorrect response is chosen, blot out the incorrect response, choose correct response by placing a cross in the appropriate box, and Be thorough in completion Write from left to right (starting at the first box) Write clearly Write within the boxes If you make a mistake - cross out the error and write the correct character in the box. If it is not possible to fit a character in a box write directly above or below the relevant box do not leave gaps 2.5 Care of survey forms Avoid damaging form. Do not staple or tape forms together. The four-locator blocks (black boxes in the corners of forms) are essential for correct reading, do not write or draw around these locator blocks. Do not write on an area designated for a serial number. DO NOT PHOTOCOPY BLANK FORMS Each form contains unique identification elements and is intended for single use. You may photocopy completed forms for your own personal use. Health Protection Surveillance Centre 15

17 2.6 Definitions and reporting instructions Reporting Instructions: In the section below which describes each field of the Panceltic core data set, each data element is defined. In addition, comments, reporting instructions and the rationale for collecting the data are given where relevant. 1. Field: The name given to the data field, e.g. Patient number. (Patient s hospital number) 2. Response required: - response question will allow only one response to be selected. Multiple - response questions will allow more than one response to be selected. Numerical - question will accept only numerical characters. Alphanumerical - question will accept numbers and letters response must be completed on every procedure recorded. Conditional - response is conditionally required when the requirement for data is dependent on the response given to other fields. t required 4. Reason for inclusion of field and desired response. Some questions are self-explanatory and therefore do not require a definition. 5. Choice(s): Choice(s) that are available under the field. Numerical frames do not ` have choices. 6. Rationale: Explanation of why a question has been included or framed in a particular manner 7. Comments: Additional information Health Protection Surveillance Centre 16

18 Definitions (core data set variables marked with * prefix): Hospital Details (Questions 1 3): Q1. *Hospital Code Q2. *Patient Number Q3. *Consultant (initials) Alphanumerical Enter identifying hospital code Alphanumerical Enter patient s full hospital number Alpha Enter initials of consultant with responsibility for care of patient Patient Details (Questions 4 5): Q4. *Date of Birth Q5. *Date of admission Reply: Reply: Numerical Date of patient s birth Date frame DD/MM/YYYY Numerical Date patient was admitted to this hospital on this admission Date frame DD/MM/YYYY Height and Weight Measurements (Questions 6 9): Q6. *Height Q7. *Weight Q8. BMI Reply: Numerical Patient s height in cm Numerical Patient s weight in Kg. Number Conditionally required Numerical Patients Body Mass Index Health Protection Surveillance Centre 17

19 Q9. When was weight taken? Numerical Enter weeks gestation when weight was recorded. Clinical Details (Questions 10 15): Q10. Previous C/S Q11. Gestation at C/S Q12. Intact membranes on admission? Q13. Hours membrane ruptured prior to delivery. Q14. Diabetes Q14. Cont d If Q14, Diabetes = Reply: Choice: Choices: If the foetal membranes were not ruptured when the patient was admitted to the hospital record, otherwise record '. Numerical Period in weeks/days of pregnancy Three-digit number: weeks + day If the foetal membranes were not ruptured when the patient was admitted to the hospital record, otherwise record '. Numerical Enter the number of hours membranes were ruptured prior to delivery Does patient have diabetes mellitus? Conditional to Part I If patient is diabetic enter if diabetes is controlled by tablet, insulin or is gestational. Tablet Insulin Gestational Health Protection Surveillance Centre 18

20 Q15. Was patient on innohep prior to C/S? Choice: Select yes if the patient received innohep prior to the caesarean section. Procedure and Surgeon Details (Questions 15 23): Q16. *Surgery type Q17. *Operating surgeon s (initials) Q18. *Date of procedure Q19. *Surgeon grade Q20. If a consultant did not perform the procedure was the surgeon supervised by a consultant? Choices: Reply: Choices: Choice: Whether this was an elective or an emergency procedure Elective, Emergency Alpha Enter initials of the surgeon who performed procedure. Numerical Date on which procedure was performed Date frame DD/MM/YY Grade of surgeon who performed procedure. If more than one surgeon was involved, record the grade of the surgeon performing the majority of the surgery. Consultant Specialist registrar Registrar SHO Other Conditional to Q19 Health Protection Surveillance Centre 19

21 Q21. *Procedure Q22. *ASA class Q23. *Wound class Choices: Choices: Select appropriate procedure from the list. Lower uterine segment C/S Upper uterine segment C/S Caesarean hysterectomy Other specified C/S Unspecified C/S ASA classification of patient at time of procedure. An assessment by the anaesthesiologist of the patient's preoperative physical condition using the American Society of Anaesthesiologists' (ASA) Classification of Physical Status schema. 1. rmally healthy patient. 2. Patient with mild systemic disease. 3. Patient with severe systemic disease that is not incapacitating. 4. Patient with an incapacitating systemic disease that is a constant threat to life. 5. Moribund patient who is not expected to survive for 24 hours with our without operation. An assessment of the likelihood and degree of contamination of a surgical wound at time of operation. Rational: Choices: The degree of contamination at the time of the operation is one predictor of whether the surgical site will become infected. 1. Clean-contaminated: operative wounds in which the respiratory, alimentary, genital or urinary tracts are entered under controlled conditions and without unusual contamination. 2. Contaminated: open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract and incisions in which acute, non-purulent inflammation is encountered are included in this category. 3. Dirty/infected: include old traumatic wounds with retained devitilised tissue and those that involve existing clinical infection or perforated viscera. Health Protection Surveillance Centre 20

22 Anaesthesia and prophylactic antibiotics (Questions 24 28): Q24. *Anaesthesia Q25. *Prophylactic antibiotics Q26. *Timing of antibiotics Q27. Antibiotic given Choices: Choices: Choices: Choices: Record the type of anaesthesia administered to the patient ne General Epidural/Spinal If and the number of administrations of prophylactic antibiotics where given to patient for procedure ne: no administrations One administration Two or more administrations Conditional The time at which antibiotics were administered to the patient. On induction t recorded At incision Within two hours prior to incision More than two hours prior to incision Immediately after cord clamping Conditional /multiple Select the antibiotics administered from the list Cefradine Cefuroxime Erythromycin Co-Amoxiclav Other (If other selected please specify) Operative Details (Questions 29 33): Q28. *Time of incision Q29. *Time of closure Reply: Reply: Numerical The time at which the first surgical incision was made. Time using 24-hour clock, HH/MM Numerical The time of skin closure Time using 24-hour clock, HH/MM Health Protection Surveillance Centre 21

23 Q30. Estimated blood loss (mls) Q31. *Re-intervention required Reply: Choices: Numerical Record the amount of blood lost in millilitres (ml) by the patient during the caesarean section as estimated by the obstetrician Number Whether surgical intervention was required. ne no re-intervention required Within 24 hours re-intervention required with 24 hours post C/S. Within 72 hours re-intervention required with 72 hours post C/S. Q31. Part I *Re-intervention time of incision Q31. Part II *Re-intervention time of closure Reply: Reply: After 72 hours re-intervention required after 72 hours post C/S. Conditional to Q31 Numerical The time at which the first surgical incision was made. Time using 24-hour clock, HH/MM Conditional to Q31 Numerical The time of skin closure Time using 24-hour clock, HH/MM Outcome (Questions 34 38): Q32. *Surgical site infection Choice: Did the patient develop a surgical site infection following the caesarean section? See Appendix A-C for a flowchart to help with diagnosing SSI s and identifying the type of SSI. Q33. *Date of discharge from the hospital Reply: Numerical Date patient was discharged from the hospital Date frame DD/MM/YYYY Health Protection Surveillance Centre 22

24 Q34. Was the patient readmitted to this hospital? Q34. Part I Date of re-admission Q34. Part II Why was the patient readmitted? Q35. Part I *Date surveillance discontinued Q35. Part II *Reason surveillance discontinued Choice: Reply: Choice: Reply: Choice: Did the patient require re-admission to your hospital post discharge. Conditional to Q34 Complete date of re-admission. Date frame DD/MM/YYYY Conditional to Q34 Please specify if re-admission was due either to SSIS or other reason. Due to SSIS Other Please specify date surveillance discontinued Date frame DD/MM/YYYY Please specify why surveillance was discontinued 30 days in study exceeded Patient died Transferred to other hospital Patient discharged and not re-admitted within 30 days Other (please specify) Questions 39 to 45 are all conditional on the patient developing a surgical site infection Surgical site infection details (Questions 39 45): Q36. *Date of surgical site infection Reply: Numerical Date of the first clinical evidence of the surgical site infection or the date the diagnostic specimen was collected, whichever comes first. Date frame DD/MM/YYYY Health Protection Surveillance Centre 23

25 Q37. Were antibiotics prescribed? Q38. *When was surgical site infection recorded? Choices: Optional Were antibiotics prescribed for a surgical site infection either by hospital clinician or patients GP? If diagnosed when the patient was an inpatient when the infection was detected select during admission. If diagnosed when the patient had returned to the hospital post discharge, select post discharge. Q39. *Infection type Choices: Choices: Definitions: During admission - the admission that the surgery took place Post discharge - If the patient comes back to the hospital where surgery took place for consultation whether admitted or not During re-admission t recorded Superficial incisional Deep incisional Organ/Space For surveillance classification purposes, SSI is divided into 1. Incisional SSI and organ/space SSI. Incisional SSI are further classified into: a. Those involving only the skin and subcutaneous tissue (called superficial incisional SSI. b. Those involving deep soft tissue of the incision (called deep incisional SSI e.g. fascial and muscle layers). 2. Organ/space SSI involve any part of the anatomy (e.g. organs or spaces). 3. Other than the incision, opened or manipulated during the operative procedure 3. See appendix A, B and C for schematic definition. 1a. Superficial Incisional Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision and patient has at least one of the following: Purulent discharge from the superficial incision Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision At least one of the following signs or symptoms of infection: pain or tenderness, localised swelling, redness or heat and superficial incision is deliberately opened by surgeon unless incision is culture negative Diagnosis of superficial incisional SSI by a surgeon or trained healthcare worker The following are not reported as superficial incisional SSI: Health Protection Surveillance Centre 24

26 Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration) Incisional SSI that extends into the fascial and muscle layers (deep incisional SSI) Classify infection that involves both superficial and deep incisional sites as deep incisional SSI. 1b. Deep SSI (incisional) Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g. fascial and muscle layers) of the incision and patient has at least one of the following: Purulent discharge from the deep incision but not from the organ/space component of a surgical site A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: Fever (>38oC) or localised pain or tenderness, unless incision is culture negative An abscess or other evidence of infection involving the deep incision is found on direct examination, during re-operation, or by histopathological or radiological examination Diagnosis of a deep incisional SSI by a surgeon or trained healthcare worker Q40. Was there a haematoma? Q41. *If organ/space, which site was involved? 2. Organ/Space SSI Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers that is opened or manipulated during the operative procedure and at least one of the following: Purulent discharge from a drain that is placed through a stab wound into the organ/space Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space An abscess or other evidence of infection involving the organ/space that is found on direct examination, during re-operation, or by histopathological or radiological examination Diagnosis of an organ/space SSI by a surgeon or trained healthcare worker Choices: Choices: Was there a haematoma present? Specific sites are assigned to organ/space SSI to further identify the location of the infection. Arterial or venous infection Vaginal cuff Other infections of the urinary tract Endometritis Other female reproductive Health Protection Surveillance Centre 25

27 Intra-abdominal (not specified elsewhere) Q42. *Did the patient die? Q42. (cont d) *If patient died Specific sites are assigned to organ/space SSI to further identify the location of the infection. Choices: Arterial or venous infection Vaginal cuff Other infections of the urinary tract Endometritis Other female reproductive Intra-abdominal (not specified elsewhere) Classification Choices: Conditional to part I An assessment by personnel of the relationship of the infection to the patient s death. Death was not related to SSI SSI caused death (patient had no underlying condition that would have caused death during this hospitalisation) SSI contributed to death (the infection exacerbated an existing disease condition, which led to the patients death) Relationship unknown Health Protection Surveillance Centre 26

28 SECTION 3 REFERENCES Health Protection Surveillance Centre 27

29 REFERENCES 1. K.B. Kirkland, J.P. Briggs, S.L. Trivette, W.E. Wilkinson and D.J. Sexton, The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs, Infect Control Hosp Epidemiol 1999: 20: V. Merle, J.M. Germain and P. Chamouni et al., Assessment of prolonged hospital stay attributable to surgical site infections using appropriateness evaluation protocol, Am J Infect Control 2000: 28: R. Plowman, N. Graves and M.A. Griffin et al., The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed, J Hosp Infect 2001: 47: Haley RW, Culver DH, Morgan WM, Emori TG, Munn VP, Hooton TP. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985;121: Cruse PE, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin rth Am 1980; 60: Gaynes R, Richards C, Edwards J et al. Feeding back surveillance data to prevent hospitalacquired infections. Emerg. Infect. Dis. 2001; 7(2): National socomial Infections Surveillance Manual. U.S. Department of Health and Human Services, Public Health Service, Centres for Disease Control and Prevention, Atlanta, Georgia, USA, Dorlands illustrated Medical Dictionary, Edition 28. W.B. Saunders Company, Philadelphia, London, Toronto. Montreal, Sydney, Tokyo. 9. Guideline for prevention of surgical wound infections, U.S. Department of Health and Human Services, Public Health Service, Centres for Disease Control and prevention, Atlanta, Georgia, USA, Culver DH, et al. Surgical site infection rates by wound class, Operative procedure and Patient Risk Index. American Journal of Medicine, 1991; 91 Suppl. 3B: 152s-157s. 11. Owens WD, Felts JA, Spitznagel EL. ASA Physical Status Classifications: A Study of Consistency of Ratings. Journal of Anaes. 1978; 49: Editorial. The ASA Classification of Physical Status- A Recapitulation. J. Anaes. 1978; Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992; A modification of CDC definitions of surgical wound infections. Infection Control Hosp Epidemiol. 1992; Office of Population Censuses and Surveys (1997) Tabular List of the Classification of Surgical Operations and Procedures. Fourth Revision. The Stationary Office. Health Protection Surveillance Centre 28

30 SECTION 4 APPENDICES Health Protection Surveillance Centre 29

31 Appendix 4.1 Schematic of surveillance process 1. Setup Surveillance Process a) Establish a multidisciplinary committee b) Ensure appropriate personnel in place c) Agree mechanism for data handling and feedback before surveillance period 2. Select Target and Enrol Population a) Enrol all patients undergoing casearean section procedures b) Review theatre and ward records. c) Fill in patient pre-operative and peri-operative details on surveillance form 3. Monitor in-patients during surveillance period a) Monitor in-patients regularly for signs of a SSI b) Follow-up Patients for 30 days OR Until patient is discharged OR During re-admission episodes within 30days 4. Complete and submit surveillance form Complete post-operative section on surveillance form for each patient at time of patient discharge whether a SSI is diagnosed or not. Re-admission and SSI sections should be reviewed if patient is re-admitted after surveillance period Health Protection Surveillance Centre 30

32 Appendix 4.2 Schematic of diagnosing surgical site infections POSSIBLE SURGICAL SITE INFECTION Infection occurred within 30 days after an operation if no implant is in place OR within one year if an implant is in place eg. hip replacement Do NOT report as a SSI Infection related to the operative procedure Do NOT report as a SSI POSSIBLE SUPERFICIAL INCISIONAL SURGICAL SITE INFECTION POSSIBLE DEEP INCISIONAL SURGICAL SITE INFECTION POSSIBLE ORGAN/SPACE SURGICAL SITE INFECTION Go to Superficial Incisional Surgical Site Infection Sheet Go to Deep Incisional Surgical Site Infection Sheet Go to Organ/Space Surgical Site Infection Sheet Health Protection Surveillance Centre 31

33 Appendix 4.2 continued POSSIBLE SUPERFICIAL INCISIONAL SURGICAL SITE INFECTION Infection involves only skin or subcutaneous tissue of incision Infection involves skin or subcutaneous tissue and deep soft tissues of the incision or involves the organ/space Check Deep Incisional or Organ/Space sheet Culture of fluid or tissue aseptically obtained from superficial incision Culture negative Culture positive* Superficial incision deliberately opened by surgeon At least one of the following signs or symptoms of infection are present: - Pain or tenderness - Localised swelling - Redness - Heat Purulent drainage from superficial incision Diagnosis of superficial incisional SSI by surgeon or healthcare worker trained in SSI definitions Do NOT report as a Superficial Incisional SSI SUPERFICIAL INCISIONAL SURGICAL SITE INFECTION * Beware that colonised wounds can yield positive results. Colonisation = proliferation of micro-organisms without host response. If unsure consult trained healthcare professional. Health Protection Surveillance Centre 32

34 Appendix 4.2 continued POSSIBLE DEEP INCISIONAL SURGICAL SITE INFECTION Infection involves only deep soft tissues (eg. fascia & muscle layers) of the incision OR Infection involves both skin or subcutaneous tissue and deep soft tissues of the incision OR Infection involves parts of body other than above that are opened/manipulated during operative procedures but the infection drains through the incision and generally does not involve re-operation Check Superficial Incisional or Organ/Space sheet Culture of fluid or tissue aseptically obtained from deep incision Culture negative Culture positive Deep incision spontaneously dehisces or deliberately opened by surgeon At least one of the following signs or symptoms of infection are present: - Fever (>38 C) - Localised swelling - Redness - Heat Purulent drainage from the deep incision, but not from organ/space of surgical site Abscess or other evidence of infection involving the deep incision is found on direct examination, during re-operation, or by histopathological or radiological examination Diagnosis of deep incisional SSI by surgeon or healthcare worker trained in SSI definitions Do NOT report as a Deep Incisional SSI DEEP INCISIONAL SURGICAL SITE INFECTION Health Protection Surveillance Centre 33

35 Appendix 4.2 continued POSSIBLE ORGAN/SPACE SURGICAL SITE INFECTION Infection involves any part of the body, excluding the skin incision, fascia or muscle layers, that is opened or manipulated during the operative procedure Check Superficial or Deep Incisional sheet Infection draining through incision (generally does not involve re-operation) Check Deep Incisional sheet Purulent drainage from a drain that is placed through a stab wound into organ/space Organisms isolated from an aseptically obtained culture of fluid or tissue in organ/space An abscess or other evidence of infection involving the organ/space that is found on direct examination, during re-operation, or by histopathological or radiological examination Diagnosis of organ/space SSI by surgeon or healthcare work er trained in SSI definitions Do NOT report as an Organ/Space SSI ORGAN/SPACE SURGICAL SITE INFECTION Health Protection Surveillance Centre 34