National Healthcare Safety Network Surgical Site Infection Reporting. Linda Johnson, MA, RN, CPHQ Felicia Alvarez, MPH Sherry Varley, RN, CIC

Transcription

1 National Healthcare Safety Network Surgical Site Infection Reporting Linda Johnson, MA, RN, CPHQ Felicia Alvarez, MPH Sherry Varley, RN, CIC

2 Objectives Describe the drivers of HAI reporting and improvement Explain your plan to conduct in hospital and post discharge surveillance Locate and use NHSN key terms and definitions Correctly complete a monthly reporting plan, SSI event, and SSI denominator

3 Drivers of Change National Quality Strategy HHS Action Plan to Prevent HAIs Affordable Care Act Value-based Purchasing Partnership for Patients

4 2012 Required NHSN Reporting CLABSI CAUTI (ICUs but not NICUs) Surgical Site Infections (colon and abdominal hysterectomy procedures)

5 Monthly Reporting Plan

6 No Procedures This Month?

7 No Procedures This Month? (cont.)

8 Surveillance

9 Post-discharge Surveillance

10 Key Term: NHSN Operative Procedure A procedure: 1) that is performed on a patient who is an NHSN inpatient or an NHSN outpatient; and 2) takes place during an operation, which is defined as a single trip to an operating room (OR) where a surgeon makes at least one incision through the skin or mucous membrane, including laparoscopic approach, and closes the incision before the patient leaves the OR; and 3) that is included in Table 1, Chapter 9. NOTE: If the skin incision edges do not meet because of wires or devices or other objects extruding through the incision, the incision is not considered primarily closed and therefore the procedure is not considered an operation. Further, any subsequent infection is not considered a procedure-associated infection (i.e., not an SSI or PPP). Skin to skin

11 Key Term: Operating Room A patient care area that meets the American Institute Architects (AIA) or Facilities Guideline Institute (FGI) criteria for an operating room when it was constructed or renovated. This may include an operating room, C-Section room, interventional radiology room, or a cardiac catheterization lab, among other areas.

12 Key Term: NHSN Inpatient A patient whose date of admission to the healthcare facility and the date of discharge are different calendar days. NOTE: A patient who is admitted to an inpatient location as an observation patient is identified as an inpatient on the first and subsequent days for the purposes of counting a location s total patient days and device days.

13 Key Term: NHSN Outpatient A patient whose date of admission to the healthcare facility and the date of discharge are the same day.

14 Key Term: Implant A nonhuman-derived object, material, or tissue that is placed in a patient during an operative procedure. Examples include: porcine or synthetic heart valves, mechanical heart, metal rods, mesh, sternal wires, screws, cements, internal staples, hemoclips, and other devices. Non-absorbable sutures are excluded because Infection Preventionists may not easily identify and/or differentiate the soluble nature of suture material used. For surveillance purposes, this object is considered an implant until it or the area/structures contiguous with the implant are manipulated for diagnostic or therapeutic purposes.

15 SSI Case Study 2

16 SSI Case Study 3

17 SSI Case Study 3.1

18 SSI Case Study 4

19 SSI Case Study 6

20 SSI Case Study 6.1

21 SSI Case Study 6.2

22 SSI Case Study 9

23 SSI Case Study 9.1

24 SSI Case Study 9.2

25 SSI Case Study 9.3

26 SSI Case Study 10

27 SSI Case Study 10.1

28 SSI Case Study 10.2

29 Creating the Denominator File Important: You cannot import incomplete or test files.

30 Creating the Denominator File (cont.)

31 Importing the Denominator File

32 Importing the Denominator File (cont.)

33 Validating the Denominator File

34 Validating the Denominator File (cont.)

35 Editing the Denominator File

36 Correcting the Denominator File

37 Success!

38 Linking Procedure and Event

39 Linking Step 1

40 Linking Step 2

41 Completing the Link

42 One final check.

43 Resources Don t take my word for it. All the rules are here: These slides are a subset of the CDC training. We will provide the training manual via .

44 Resources (cont.) CDC staff are the experts. Please use them for protocol, questions, definitions, etc. The NHSN maintains an extensive library at

45 Questions? Thank you! Linda, Felicia, and Sherry