2017 NHSN Training – SSI Surveillance with Case Studies


>>Good morning, everybody. It’s 8 o’clock so we’re going
to go ahead and get started. For today, we will be focusing
on SSIs and MDRO/CDI LabID. We’ll be covering both protocols and analysis. We’ve got four presenters today. We’re really excited about these presentations. Our last session today at 3:30 will actually
be a panel discussion with all the presenters who presented Tuesday through today. It’s going to be kind of like an
open panel Q and A from 3:30 to 4:30. We hope you’ll all stick around for that and ask
any additional burning questions you may have. Again today, we will have our polling questions so you should see your orange
baskets there with the clickers. And I think with that being said, you guys
are all experts at how this works by now. So I will turn it over to our first
speaker who is Victoria Russo. She is an infection preventionist
with our protocol and training team. Her subject matter expertise is with
surgical site infection surveillance. We’re very happy to have her with us. She’s one of the newer members
of our team this past year. She worked as an IP in Michigan
in a large hospital in Michigan. So come on up, Vicki, and thank you all. Let’s get started. [ Applause ]>>Good morning, everyone. It’s so nice to see you here Thursday morning. We’re in our fourth day of training. And thank you for that introduction, Maggie. So like what Maggie said,
my name is Victoria Russo. I am one of the SSI subject matters
here — experts here at NHSN. I work alongside Janet Brooks and
Denise Leaptrot to help answer your SSI questions. So if you email the NHSN mailbox you’ll
more than likely hear from one of us three. I am new to the protocol and training
team within the past several months and like Maggie said, I recently worked as an IP in a large health system
outside of Detroit, Michigan. I will be covering the SSI protocol today. It is great to have all of you here that are
able to join us in Atlanta and then also to all of you web streamers that are
able to join us this morning. This is a longer presentation. We have a lot of material to cover, but we
will have a break in between so you can get up and stretch and get a coffee
refill, go to the restroom and then at the end hopefully we’ll have a
little bit of time for questions. Before I get started, I wanted to
acknowledge my mentor here, Janet Brooks. She is the current SSI subject
matter lead here at NHSN. I wanted to note that Janet Brooks will
be retiring in a couple of months here at NHSN, and she will be surely missed. I have been working with Janet
intensely to prepare for taking over as the SSI subject matter expert lead here. We do wish her the best in her retirement. And we will miss her and all the
contribution she has made here to NHSN within the past several years. So if everybody can just join —
a round of applause for Janet. [ Applause ] So yeah. It’s a major loss, but we are
very, very happy for her and her retirement. So congratulations, and Janet will
actually be joining me at the end for any questions that you may have. So I’m going to go ahead and get started. So our objectives today — so upon completion of
the program, you as the participant will be able to identify SSI’s and key terms using specific
case studies, describe SSI 2017 changes. I will mention that this year for 2017
there were not a lot of drastic changes made to the protocol, but there were
some minor changes that we did make, and I will discuss those as we go along. You as the user will be able to complete
the SSI event form and the SSI denominator for procedure form, understand how to
link an SSI event to a procedure record and apply NHSN SSI criteria
to specific case scenarios. Now all objectives will be reviewed within
the context of the 2017 NHSN updates. Okay. So SSI. Why do they matter? Well, they matter because each year there
are an estimated 157,000 HAI SSI infections in the United States. There are an estimated 8,205 deaths associated
with SSI each year, and an estimated 11 percent of all deaths in the ICU setting
are associated with getting an SSI. So these statistics highlight
the importance of SSI prevention and why is it important to
conduct SSI surveillance. And not only is there significant morbidity
and mortality associated with an SSI, but SSI are the most common healthcare
associated infection and they account for 3.2 billion in attributable cost
per year in acute care hospitals. An estimated additional 11 days of hospitalization may occur
for a patient that gets an SSI. And SSI are the most frequent
cause at approximately 20 percent of unplanned readmissions after surgery. So I’m going to go ahead and get
started on basically the basic — I like to call this the NHSN SSI landing page. I know yesterday if you were
able to catch Henrietta Smith, she did a wonderful presentation at lunch
yesterday about navigating our NHSN webpage. But because we’re talking about SSI right
now, I wanted to start from ground zero and for all those that may be new IP’s in
the field or professionals that have been out in infection prevention for some
time, I think it’s good to just go through briefly exactly what
we offer on this landing page and what you will find within each section here. So this is the main SSI section
on the NHSN webpage. I’m sure probably a lot of you
have referred to this section. I know myself I refer to this section all the
time when I’m performing SSI surveillance. There is a wealth of information here. It’s very user friendly, and there’s a lot
of great resources here so what I’m going to do is I’m going to go through each
section and pull each section apart and kind of give you a quick and dirty as far as
what you’ll find within each section. So the first section here you
will see the training section, and the training section basically all of
our training resources are housed here. The most up to date and current
trainings are housed here. The training that’s given today will be
eventually uploaded here later in the spring. If there’s any hot topic or any quick
learns, those you will find here as well, and like I said, it’s a great resource. So if there’s new IP’s or if you have — if you’re a new IP in a program or if there’s
a new set of IP’s within your health system, have them go through these trainings. It does not hurt. And it doesn’t hurt going
through these multiple times because there might be some things you
miss as you first go through these. And then for those seasoned IP’s,
I like to call the professionals that have been in the field for some time. It’s also a really nice refresher sometimes because there’s a lot of
information that’s out there. Now, this right here is the protocol section, and this is where you will find
the most current 2017 SSI protocol and also you will find here chapter one, which
is the NHSN overview chapter, chapter two, which is identifying healthcare
associated infections chapter as well as the patient safety monthly reporting plan
chapter, and these are all current as of 2017. I want to mention while I’m at this
particular section here that when the — when the protocol was first published early
in January, there was an error that occurred for table 3 and table 4 of the chapter
9 SSI protocol where the table 3 and table 4 there was some content at the
bottom of these tables that was cut off, and this was noticed very early on. It was corrected very early on, but just make
sure whatever protocol you’re working off is the most current and up to date one, because I
actually just got a question the other day about this because they were working
off the initial copy that went out, but just make sure you’re
working off the most current copy. Okay, so this is the FAQ
section for SSI surveillance. Every protocol has an FAQ section. So our SSI protocol has a current
FAQ document, which is for 2016. Our 2017 document we’re actually
working on currently and should be available later in the spring. The current document is about 11 pages long. I will note that the 2016 document
is still a very valid document, still refer to this document, and
there’s a lot of good information here. Don’t just wait for the 2017. Still refer to what’s out there. I will say that I do feel like this document
is under utilized, and the reason I say this is because we get a lot of questions every week in
our NHSN mailbox that can easily be addressed within this document, and it’s fine to email us. It’s absolutely no problem, but you may get
a quicker response or quicker turnaround if you just refer to the FAQ document
because it takes a little longer, as you know, emailing the user mailbox. So I definitely encourage you to utilize this. I know that I have mine attached
to my protocol and then when I was in the hospital I always flip to
it because it was right there. And then this section right here
is the — let me make sure here — so this section right here is the
data collection form section and then within this section you will find
the current data collection forms and their table of instruction. So as you can see here, you
will find the SSI event form, and you will find the denominator
for procedure form here. Also, these forms have their own table of
instructions and basically what the table of instructions is it helps guide you through
filling out all the data fields on the forms. Also, an awesome tool and I would say
that definitely utilize this as well because sometimes we do get questions
about filling out the particular field. So — and then this tab right here
is the CMS supporting materials tab, and you will find here resources
for CMS as well as up to date reporting instructions
and deadlines for CMS as well. And then finally, we have our
supporting materials section, which is a really important section
because you will find here the ICD-10 PCS and CPT code documents for all
the NHSN operative procedures. Also you will find the updated guidance for how
to determine HPRO and KPRO procedure details as well as the updated guidance for spinal
level and approach for fusion cases for ICD-10. And then make sure that you’re always
working off the most up to date and current code documents because
sometimes I know — because they’re in Excel, you may save them to your desktop
or what not and just make sure as you’re doing your surveillance
you’re working off the most up to date and current code documents
as they get published. So now let’s move on to the
month reporting plan. So the monthly reporting plan is
where you tell us what you’re going to be following as a facility. Plans are the road map to your data. Only data included in plans will be
used by CDC and aggregate data analysis. Now plans drive much of the business
logic of the NHSN application. You must have one for every month of the year. And remember that if you are following a certain
procedure within your reporting plan you have to follow all elements of that procedure. So that means you want to follow
superficial incisional SSI, deep incisional SSI and organ space. Just because NHSN sends on the deep
incisional SSI and organ space SSI to CMS only, it does not mean that you don’t report
to us the superficial incisional SSI’s. Also, events where PATOS equals yes,
although those are not furnished to CMS from NHSN, those still have to
be reported to us here at NHSN. Your in plan data will be analyzed internally
and also by CDC against other facilities. So I do want to touch on the concept
of active surveillance methods. I know that yesterday Suparna Bagchi
did a wonderful presentation on validation, and talked about some other
methods that you can do as a facility to detect surgical site infections. So there are different ways to perform SSI
surveillance within your facility by review of medical records or surgery
clinic patient records. Some of these methods may include
admission, readmission or ED or OR logs, perhaps combing through patient
charts looking for signs and symptoms of surgical site infection, looking at
labs, x-rays, other diagnostic test reports, reading your nursing notes, your physician
notes, your mid level provider notes. And then also I think this is
extremely important, getting out there and really visiting those areas within
the hospital, your ICU’s and your wards, getting to know your staff, being
comfortable with your staff, making your staff comfortable approaching
you, participating on multidisciplinary rounds when you can because you’re rounding on
these patients real time within the hospital, and you get to hear real time what
might be going on with these patients. Remember that you can have a surgical site
infection without a positive wound culture so don’t just rely on your microbiology
report to do your SSI surveillance. There are a lot of other
methods that you can do. So once that patient goes home, there are also
several post discharge SSI surveillance methods. Surgeon and/or patient surveys
by mail or phone may be helpful. Reviewing postop clinic records. Some facilities are connected
where you can actually go in and then view postop clinic records. Patient was seen in the office after surgery. Also maybe perhaps looking at line list
of all readmissions with diagnoses, line list of ED admissions with diagnoses, perhaps having ICD-10 PCS
discharge or procedure codes. Basically here some facilities have
built in diagnostic codes that can be run after a patient is discharged and
potentially this can provide a heads up if that patient is readmitted that perhaps
they have a surgical site infection. Also, another important point here
is notification between facilities because of course sometimes the patient
may have surgery at your facility but perhaps then they show up down the
road with a surgical site infection, and I think it’s really important for
communication to occur between these facilities to help one another out to give each other a
heads up as a potential surgical site infection. Remember that criteria must be met regardless
of where you detect the surgical site infection. Now when performing SSI surveillance, there
are two main forms that you would use. On the left is the — I’m sure most —
a lot of you are familiar with this, but this is the denominator
for procedure form, and this is where you put all your
denominator data on this form. On the right hand side is your
event form or your numerator form. And this is where you collect
your event information. And remember that these forms
have table of instructions to help guide you through all of the fields. These forms capture the content that
is entered into the NHSN application. Some facilities do have a vendor provided system
where the data actually automatically uploads into the application, but
these are your basic forms. Now, this is a screenshot that was taken
from chapter two in the NHSN manual, and what you can see that is crossed off here
in red means that this guidance is not available to surgical site infection surveillance. So there is no seven day
infection window period for SSI because SSI either have a 30 day
or a 90 day surveillance period. The POA, the HAI or the 14 day repeat
infection time frame also do not apply to SSI as each visit to the OR will start your
30 day or your 90 day surveillance period. Now SSI does have a secondary bloodstream
attribution period, and we will talk about this. Now the pathogen assignment guidance is not
crossed off here, but in chapter two it states that its based on the repeat infection
timeframe and the infection window period that SSI do not have, but
we’ll talk a little bit about pathogen assignment when it comes to SSI. Okay, so what is an NHSN operative procedure? An NHSN operative procedure is a
procedure that is included in the ICD-10, PCS or CPT NHSN operative procedure code
mapping and takes place during an operation where at least one incision
including laparoscopic approach and cranial Burr holes is made
through the skin or mucous membrane or reoperation via an incision that was
left open during a prior operative procedure and takes place in an approved operating room. I wanted to mention that there was one
modification or change that occurred between 2016 and 2017 as far as this definition. So we added the — and if you can see
in the second bullet here, the bullet — you’ll see cranial Burr holes was
added, and this was added because — into the CRAN section this year because
percutaneous Burr holes can be an approach for procedures on the brain, and we wanted
to make sure to capture these approaches. So this is new for this year. So your date of event for an SSI is
the date when the first element is used to meet the SSI infection criterion that occurs for the first time during
the surveillance period. SSI’s are always reported at the deepest level
that they occur within the surveillance period. If during the surveillance period a patient’s
initial SSI meets criteria for a deeper level, then the date of event should be
the date for the deepest level. Let me give you an example. So on day one, we have a patient
that has a COLO procedure. On day six, they have a date of event
for meeting a superficial incisional SSI. Now on day 25, they have a date of
event for meeting organ space IAB SSI. So you’re still in your 30
day surveillance period. So what do you do here? What do you report? What is your date of event? That date of event is going to be for the
deepest level that is involved with that SSI. So that’ll be day 25. You never want to report more than
two SSI’s or more than one SSI. Just going to be one SSI with a
date of event for the deepest level. Now if it meets the deeper level outside of the surveillance period,
you cannot upgrade the event. Your surveillance period is done, and then you
would go with whatever it was called during that particular surveillance period. But we get this question sometimes. Oh, do I have two SSI’s now? No. You have one. Remember, it’s at the deepest
level that it meets as long as it’s within that surveillance period. Now, I wanted to mention
briefly pathogen assignment. Pathogen assignment, like I said,
the guidance in chapter two is based on the repeat infection time frame and
it is not used for SSI surveillance. SSI are procedure based, and they have
long surveillance periods so you’re going to have your 30 or your 90
day surveillance period. They can progress to a deeper
level, like I said, during a surveillance period,
and a new pathogen can be found. Now if a new pathogen is found, what you want
to do is you add that new pathogen on as long as it’s within that surveillance period. There are lists — and I know Kathy
briefly mentioned this and a couple of different presenters mentioned this, but
there are a list of certain excluded organisms that would — we would never be
able to apply to SSI definition. And they’re listed here, and the reason
why we wouldn’t use these organisms is because they typically are causes of
community associated infections rarely known to cause healthcare associated infections
and therefore that’s why we exclude them. Okay, so for wound closure, the
definitions of a primary closure and a closure other than
primary did not change for 2017. So primary closure is defined as closure of the skin level during the original surgery
regardless of the presence of wires, wicks, drains or other devices or objects
extruding through the incision. So basically some portion of the
skin is closed at the skin level. Now a nonprimary closure is defined as
closure of the surgical wound in a way which leaves the skin left
completely open during the surgery. Retention sutures can be both
primary or a nonprimary closure. This is a picture here, and I know Janet
used this last year in her presentation. It’s a really nice picture to
show you on the left hand side. These are examples that three
of primary closure — as you can see here, some portion of
the skin is closed at the skin level and on the right hand side, these are closures
other than primary where there’s no portion of the skin that are closed at the skin level. Now in the past, CMS only
received primary closures but after the new rebaseline CMS is
getting procedures with both primary and nonprimary closures in the denominator data. So wounds may or may not be described as
packed with gauze or other material and may or may not be covered with plastic, wound
VAC’s or other synthetic devices or materials. Wound VAC’s on wounds does not mean that the
wound automatically has a nonprimary closure. So if they close part of the incision and
then place a wound VAC in the open part, this is still deemed a primary closure. As you can see here, these are actually
pictures of closures other than primary. The left hand picture is a wound that is
left completely opened and packed and then on the right side is a wound
that is left completely open with a wound VAC placed on the wound. Okay, so everybody has their clickers. We’re going to go ahead and get started today. We have a few — we have about 11 or 12
cases to go through today, but we’ll go ahead and get started on our first case. But I want to mention that all the cases
that I’m presenting today have been — are very realistic in that they’re
not real cases that were sent to us but they’re pretty much realistic
like a case that is sent to us. We want it to be as realistic as possible here. So our first question today is we have
a 56-year-old female undergoes an XLAP and a COLO procedure and has mutiple
trocar sites closed primarily but one that is left open. Is this procedure a primarily closed procedure? A lot of respondents here. That’s good. All right, let’s get to about 70. Almost there. All right. Let’s see what you think. Yes. Great job. 71 percent state that this is a primary
— a procedure primarily closed. Let’s talk about this. What’s the rationale for this? Well, the skin is closed at some
points along the skin incision. Remember that if any portion of the
skin is closed at the skin level by any manner a designation, a primary
closure should be assigned to the surgery. If a procedure has mutiple incision
or laparoscopic trocar sites and any of the incision are closed primarily, then the procedure technique is
recorded as a primarily closed procedure. Okay. So let’s get into secondary BSI scenarios
because we all know that if we have a patient with a surgical site infection, and we have a
blood culture at the same time that we’re going to try to see if we can call
that blood culture secondary to that SSI or secondary to another source. So there are two scenarios where blood
specimens can be deemed secondary to a surgical site infection. The first scenario is the secondary
BSI attribution period for an SSI which is a 17 day period that includes your date
of event, three days prior and 13 days after. At least one organism from the blood
specimen must match an organism identified from the site specific infection
that is used as an element to meet the NHSN site specific
infection criterion. Let me give you an example. We have a deep incisional SSI with a
wound culture positive for Staph aureus. We also have a blood culture that’s
positive for Staph aureus and it falls within that secondary BSI attribution period. This would meet criteria for a secondary BSI. The second scenario would be an organism is
identified in the blood specimen and is used as an element to meet the NHSN
site specific infection criterion. And with this, for example, you might
have a positive blood culture that is used as an element, for an example,
on the organ space, IAB SSI, and it’s part of the definition,
and it meets that way. You cannot apply scenario 2 to a
superficial or a deep incisional SSI as blood is not an element part of this
criteria as you can only use a matching pathogen for superficial or deep incisional. I wanted to mention that there
is — so you have a date of event within a certain surveillance period. The 13 days that fall after
that date of event to fold in that blood culture can actually fall outside of the surveillance period
based on the date of event. So for example, you have a
date of event that occurs on day 29 of a 30 day surveillance period. The secondary BSI window will actually
extend beyond the 30 day surveillance period. So there’s going to be a
little room here to utilize that blood culture to call it a secondary BSI. Why does SSI have its own
secondary BSI attribution period? Well, for other HAI’s, the secondary
BSI attribution period is determined by using the infection window period and the repeat infection time frame,
and these do not apply to SSI. Okay, so here you will see — because I
know some of us like to see a visual — of the secondary SSI secondary
BSI attribution period. So what you see here you have your date
of event for an SSI on hospital day 13. You’re given three days prior and you’re
given the 13 days after for a total of 17 days to be able to fold that blood
culture into that SSI. All right. So let’s move on to infection
present at time of surgery, PATOS. So infection present at time of surgery
denotes that there is evidence of an infection or an abscess at the start of or
during the index surgical procedure. In other words, it is present preoperatively. This field is a required field, and it
is found on the SSI event form only, not on the denominator for procedure form. The evidence of infection or abscess must
be noted or documented intraoperatively in an intraop note or immediate postop note. I will note because we get
questions sometimes on this that the PATOS field has nothing
to do with the denominator form. You’re only going to be concerned about PATOS
equals yes or no when you actually have an SSI. So that’s the only — the field is
only housed in your numerator form. You want to only select PATOS equals yes
if it applies to the depth of the SSI that is being attributed to the procedure. So if the patient has evidence of an
intraabdominal infection at the time of surgery and then later returns with an organ space
SSI, the PATOS field would be selected as a yes. Now if the patient returned with a
superficial or deep incisional SSI, the PATOS field would be selected as a no
because it’s not the same tissue level. The patient does not have to meet the
NHSN definition of an SSI at the time of the primary procedure, but there must be
notation that there is evidence of infection or abscess present at the time of surgery. I wanted to mention that path reports or
preoperative imaging does not count for PATOS. Identification of organisms alone using culture
or nonculture based microbiologic testing or on path reports from a surgical specimen
does not count to be used towards PATOS. The verbiage colon perforation, necrosis,
gangrene, fecal spillage, nicked bowel, inflammation, none of these
alone count for PATOS equals yes. There has to be documentation
on the actual infection so for example, an abscess or purulence. That’s what we need to see, and it has
to be in that actual operative report. This is a required field, and it — like I
said it’s only housed on the numerator form. And remember that they don’t have to actually
meet the criteria for NHSN SSI at the time of that index procedure,
but there has to be evidence of an infection or abscess at that time. I wanted to note that there’s
a very nice six minute — about six minute PATOS quick learn which is
housed under our training section for all of those of you that may
have not seen this before. It’s only six minutes, but it goes
through PATOS in a little bit more detail. Also within our SSI protocol, we have
more details in examples of PATOS, more examples that are given
that might be helpful to you if you want to — want more information on PATOS. Remember that PATOS events are not sent to
CMS, and they don’t impact your internal SIR. But they are available for you and your own
analysis and your quality improvement practices. I want to note that we do get a lot of questions
on the impact of PATOS and SSI and PATOS in relationship to the rebaseline. And this will be discussed in the
presentation following my presentation today by Rebecca Konnor when she
discusses SSI analysis. Okay, so let’s get into our second case. So we have a patient that was admitted
with a perforated diverticulum, and a CT showed multifocal abscess
collections in the lower abdomen and pelvis. The patient was off to the
OR for a COLO procedure. The surgeon documented abscesses and
purulence throughout the abdomen. One week later, the patient meets
criterion for an organ space IAB SSI. Does this patient meet the criteria for PATOS? No or yes. Responding fast. Good. All right. Let’s see what you all think. Good job. PATOS equals yes. Yes. Abscess was noted at the organ space
level at the time of the initial procedure. Same tissue level. This does meet the criteria
for PATOS equals yes. Good job. Another question. The SSI is related to an
infection that was PATOS. Therefore, it’s an ongoing process, and this
event does not have to be reported at NHSN. True or false? False. It is an event. It is an SSI. PATOS equals yes is not an
exclusion for reporting to NHSN. Infections that meet SSI criteria and have
the PATOS field as a yes are reported NHSN if you are following that
procedure in your plan. So what is the definition of an
NHSN inpatient operative procedure and an NHSN outpatient operative procedure? Well, an NHSN inpatient operative procedure is
a procedure performed on a patient whose date of admission to the healthcare facility and the
date of discharge are different calendar days. An NHSN outpatient operative procedure is a
procedure on a patient whose date of admission to the healthcare facility and the date
of discharge are the same calendar day. Outpatient procedures may take
place in ambulatory surgery centers, hospital outpatient departments
or other healthcare facilities. You want to make sure whatever
method you are using to capture all of your inpatient procedures are
capturing all them accurately because sometimes procedures may
be billed as outpatient procedures, and they actually meet the criteria for an
inpatient — NHSN inpatient operative procedure. Then you need to make sure that
you’re capturing these procedures. For example, a patient may have a HYST procedure. It’s billed as an outpatient procedure,
but they end up spending the night, so it actually meets NHSN criteria
for an inpatient operative procedure. The billing status may be different. Therefore, you want to make sure you
are capturing all of these cases. So do whatever you need to do within your
facility and run whatever codes you need to run to get a complete denominator data here. It might just be a matter of
filtering cases within a line list. The mapping of NHSN operative procedures
for both ICD-10 PCS and CPT codes is located on the SSI section of the NHSN
website under supporting materials. Note that this mapping is available as guidance
for both acute care hospital facilities as well as ambulatory surgery centers
on the NHSN website. It is extremely important that facilities
ensure that they are using the most up to date set of procedure codes. Each time NHSN uploads and updates an email
is sent out to all the NHSN users and the date of the update will be reflected at the top of
the page just above the link to the mappings. Most are aware but remember that
NHSN ICD-9 operative procedure codes for the category OTH other were not mapped ICD-10
PCS and CPT codes, and most of the procedures in that group are no longer
considered NHSN operative procedures and could not have SSI attributed to them. For NHSN surveillance, an SSI
can only be attributed to one of the 39 NHSN operative procedures. Okay, so I do want to highlight
some updates that we have for you. So this is the screenshot
that highlights new features of the updated ICD10 PCS code mapping
document for 2017, and let me just quickly go through here what some of
these new features are. The first feature is there is
now an accompanying description for each operative procedure code. Also there is — each column
can be sorted and filtered now. There is a combined list of codes for all
operative procedure categories as well as individual worksheets for each
operative procedure category. It’s really nice because
you can just go to one tab, and you have all of your 39 NHSN
operative procedure categories right there, and then also there’s an index tab which
is the purple tab that contains hyperlinks for each operative procedure code worksheet, and these new features hold
true to CPT codes as well. And this was based on hearing from users. We wanted to make it a little bit easier
for you to search, navigate the codes and so we took your suggestions in mind here. The ICD10 and CPT code FAQ document
is actually currently being updated and will be available later in the spring. So there will be an updated
FAQ document for that as well. I just took a screenshot here. I wanted to show you, for example, this is the
APPY tab that is on the ICD10 PCS document. You can see here now it’s
really — I like this — it’s really nice because you have the
ICD10 codes on your left hand column, but then you have your code descriptions so
now there’s an accompanying description to kind of just tell you what that procedure is. It’s really, really nice. So this is new for this year. There’s descriptors now housed
within these documents. So for both ICD10 and CPT
codes, you can actually search within a single code group within the documents. For those of you that have never searched
within the actual documents themselves, it’s pretty easy, but let me just quickly run through here how you would
go and look for a code. So if you’re in the actual document, there’s
a — as you can see in the far right corner, there’s a set of binoculars where you go to
find and select and then here you would punch in your code and then it would look for that
particular procedure within the document. You could either go through — I search
by the all ICD10 PCS codes combined because they’re all going to be right there. But you can actually search the entire worksheet
if you chose to do it that way as well. So what I did is I searched for a laminectomy, and this code was 0SW30JZ, and
it actually — it found it. So it highlighted it here. It brought it up. I know that this is an NHSN operative procedure. It is very important to note that ICD10
PCS codes they never contain the letter O or the letter I to avoid
confusion with the number 0 and 1. So if you’ll enter the letter O instead
of the number 0 or the letter I instead of the number 1, you will not —
you’ll get a little alert there that says we can’t find what you’re looking
for pop up because you can never use O or I in these operative procedure codes. We get questions sometimes sent
to us where a user may not be able to find a particular procedure to see
whether it’s an NHSN operative procedure. We look closer at it, and we realize that they
actually put the letter O in instead of a 0. So just pay attention to that when
you’re looking for procedure codes. Okay, so now we’re going to move on to
talk about completing the denominator for procedure information forms so
this probably looks like all of you. You’re behind your desk. You’re at work. You’re completing the form, happy. All right. Let’s move into this. So in regards to denominator data,
the collection period is one month. You want to complete a denominator for
procedure record for every operation, meeting the NHSN operative procedure
definition that was done during that month if it is in your monthly reporting plan. You want to submit your data within a month
of the end of a 30 day surveillance period or one month from the 90
day surveillance period. The goal is to submit in a timely
fashion , but it is most important to have all your reporting complete
well before the CMS deadlines because once your data has gone
on to CMS, it cannot be upgraded. It cannot be modified. It cannot be deleted, changed. It is frozen. It is gone. It is with CMS. So it’s really important if you can
to just try to stay on top of that and get those in before the deadlines. I want to talk about a few reporting
instructions that come up frequently. So let’s discuss this first
reporting instruction here. Now, for this instruction, if procedures in more than one NHSN operative procedure
category are done through the same incision during the same
trip to the OR, you want to create a record for each procedure that you are
monitoring in your monthly reporting plan and use the total time for
the duration of each record. So let me give you an example. A patient has a coronary artery bypass graft
with a chest incision only so this is a CBGC. And they also have a mitral valve
replacement which is a CARD procedure. The time from procedure start time to
procedure finish time was five hours. So a denominator for procedure form is
completed for the CBGC and another is completed for the CARD procedure, indicating the duration
as five hours and zero minutes on each form. Remember, there’s going to be two
denominator for procedure forms and both of these forms will have
the duration of five hours. So don’t split the time. So the next reporting instruction states that
if the patient goes to the operating room more than once during the same admission
and another procedure is performed through this same incision and if the start
time of the second procedure is within 24 hours of the finish time of the original operative
procedure, what you want to do is you want to fill out only one denominator for
procedure form for the original procedure, combining the duration for both procedures
based on the procedure start time and finish times for both procedures. Let me give you an example. So we have a patient that has a COLO procedure. They have a COLO performed on a Tuesday morning. The COLO procedure had a duration
of three hours and ten minutes. Now on Tuesday evening, they actually go back
to the OR where the COLO incision is reopened and now they perform an XLAP
to repair a bleeding vessel. The duration of the second procedure
was one hour and ten minutes. So because this XLAP procedure was
within 24 hours of the finish time of the original operative procedure, you will
only fill out one denominator for procedure form and that will be for the COLO procedure with the
combined duration of four hours and 20 minutes. So you will not fill out a denominator for
procedure record for the XLAP procedure. And the concept here is that the
second procedure is only being done because the original procedure had a
complication that needed immediate attention and therefore it is treated as if it were
an extension of the original procedure. If the second procedure is done through
the same incision at greater than 24 hours from the finish time of the original
operative procedure, then you will have to fill out a completely separate denominator form. Now if the wound class has changed, you
will want to report the higher wound class. If the ASA class has changed, you
want to report the higher ASA class. When a patient returns to the OR within 24 hours
of the end of the first operative procedure, you will assign the surgical
wound class technique that applies when the patient leaves the OR
from the first operative procedure. So now for this next denominator reporting
instruction, for operative procedures that can be performed via separate
incisions during the same trip to the OR, you want to fill out two separate
denominator for procedure records. To document the duration of the procedures, you want to indicate the procedure surgery
start time to procedure surgery finish time for each procedure separately. Or alternatively, If this information is not available, you
will take the total time for the procedure and split it evenly between
procedures because often times we see in bilateral procedures they will know
perhaps how much time they spent on one side and then before they moved to the
other side and if they don’t note this, what you want to do is you want to
take that total time and you want to divide it evenly down the middle. So for example, a bilateral breast procedure
is the exact same procedure same day, different sites. You’ll have separate denominator for procedure
records for these operative procedures. So the ICD10 PCS or CPT codes
they do remain as optional fields on the denominator for procedure form. When entering a code into the NHSN application,
if the code is entered into the ICD10 PCS field or CPT field first, this will then
autofill the procedure code name. So as you can see here, I entered a COLO code
and then autofill that it’s a COLO procedure. It recognized that. It knows it’s a COLO procedure. If procedure name — if the procedure
code name field is filled in first, you can also manually enter the code as well. Remember that this is not a required field. And then in here, what I did was — this
is an example of a KPRO or knee prosthesis and so here we actually — the knee
prosthesis field was selected first and then the user entered the CPT code 27437. It accepted it. It recognized it. That this is an NHSN operative
procedure code without any alert. And it confirms basically yes, this
is a NHSN operative procedure. So let me talk about a few examples of
code error entry because this can happen. We’re human. In this example, the selected procedure
code name COLO was entered first and then the code OD190K4 was entered. As soon as this code was entered,
the alert message was displayed here. It notes that the code entered
does not match a COLO code. The alert actually notes that the
code entered is a small bowel code. So it’s smart enough to tell you that
this is actually not a COLO code, and it’s a small bowel code. Now in this example, the ICD10 PCS code 0RQJOZZ
was entered in the ICD10 PCS field first. As soon as the code was entered, it disappears
from the field, and this alert is displayed. And this — because this
code is not found in any of the NHSN operative procedure
categories, why do we think that? I’ll give you a little hint. Oh, be careful when you’re entering these
that you remember you don’t want to use — ever enter a letter O or the letter
I because those — they don’t exist. Those aren’t used within these
operative procedure codes. So pay attention to that,
and it recognized that. So if you go in and you fix it, then
it’ll recognize that as a legit NHSN code. So now wound class is a required field
on the denominator for procedure form. Wound class is an assessment to the
likelihood and degree of contamination of a surgical wound at the
time of the operation. It should be assigned by a person directly
involved in performing the operation. This is rarely assigned by the IP. NHSN does not make wound class
determinations for specific scenarios. I will say that I probably receive a couple
of emails a week we receive at NHSN asking us to make a wound class determination
on a particular case. And we’re not trying to be rude. We’re just — we will politely
respond back to say that we cannot make those
determinations for you. It really needs to be assigned by
someone that’s directly involved in that procedure during that case. We’re — here at NHSN we
don’t know what went on there. We don’t — we cannot make that call for you. So just note that we will not be able
to make a determination for you as far as any wound class determination. Remember, it is a required field. There are, though, a set of codes that
can never be coded as a clean wound class. And the procedures that can never be entered as
a clean wound class are APPYs, BILIs, CHOLs, COLOs, RECs, small bowels and VHYS. In the application, clean is actually not on
the drop down menu if you’re trying to enter these as clean procedures. If one of these procedures at your
facility is assigned as a clean procedure, you need to discuss this with
your OR and get this changed because it shouldn’t be assigned
as a clean procedure. CSEC, HYST or OVRY can be a clean wound class. A surgeon can actually make a determination
that these can be clean procedures based on the particular events and
findings of an individual case. We do get this question sometimes. So note that these can actually
be a clean procedure. Wound class again — I’m going
to say this one more time, but wound class cannot be
set by us here at NHSN. It has to be set by someone who
is part of the surgical team based on the findings of each particular case. Okay. So moving on to trauma. Trauma is a required field on the
denominator for procedure form. So what is a trauma? A trauma is — you would indicate a trauma
equals yes if the operation was done because of a recent blunt or penetrating trauma. Now if the bowel is nicked or
perforated during an operative procedure, this should not be listed as a trauma case. An example of a trauma may be the patient
falls down the stairs and fractures their hip. This is considered an immediate trauma. In complex trauma cases often times,
these patients have to return to the OR sometimes multiple times for stage procedures
so in these cases, each time that they go back to the OR, you would indicate that trauma
equals yes because this is an acute — this is a current trauma and they’re
being done in staged procedures. But an ongoing repair of a past trauma does not
mean that you would indicate trauma equals yes because this is a trauma in the past. So here is something new for 2017. I wanted to highlight this here that we have
updated the emergency procedure definition for 2017, and our current 2017 definition
is an emergency procedure is a procedure that is documented by the facility’s protocol
to be an emergency or urgent procedure. That’s what it is. NHSN in the past, we received a lot of requests
from users to update the emergency definition. The old definition read an emergency
procedure was a nonelective, unscheduled operative procedure. And emergency operative procedures
are those that do not allow for the standard immediate preoperative
preparation normally done within the facility for a scheduled operation, though there
were some concerns with this definition. The first concern was in terms of the
old definition that it was very hard to call a procedure an emergency even
though it was one since they were — almost always had time to
do the proper skin prep and to somewhat stabilize the
vital signs of the patient. Sometimes facilities had to dig deep in the OR
record and the preoperative notes to determine if the procedure actually met the NHSN criteria. So NHSN we discussed this with several
facilities with our surgeon consultant and we all agree, we all believe that
most hospitals do have something in place to note the procedure as an
emergent or urgent procedure. This is often noted in the anesthesiology
record or maybe perhaps in the OR record. So we actually feel now that our
updated definition will be more accurate and consistent than the old one. But if your facility does not have this noted
anywhere and your OR, your anesthesia record, you can go ahead and use the old definition. That’s okay. We are okay with that, but we wanted to
update this to make this a little bit easier for the facilities that are having
a harder time to make this call. Now procedure details on the denominator
for procedure form, we have to — if you’re filling out Scope, it’s a
required field so you want to check yes if the NHSN operative procedure was a
laparoscopic procedure performed using a laparoscope or robotic assist approach. Otherwise, you would check no, but this
is a required — this is a required field. You would select yes if the scope was used to harvest a donor vessel during
a coronary artery bypass graft for both the chest and donor
incisions were made. Basically, it lets us know that the
leg was done via a scope approach. So for entering the scope field, the
denominator for procedure information, the ICD10 PCS codes are very helpful. I don’t know if you all know this, but I learned
this actually when I started here at NHSN. This was something new to me. The fifth character of all ICD10 PCS
codes denotes the approach method. If the fifth character is a zero, this denotes
it as a procedure with an open approach so this would automatically
be a scope equals no. Now if the fifth character is a four, this
notes a percutaneous endoscopic approach so this will be a scope equals yes. So as you can see here, this
is a COLO code 0DTN4ZZ. That fifth character is a four,
so this is a scope equals yes. So I think it’s cool, but — I don’t
know if you all knew that, but — now in this example, the
fifth character is a zero. So scope equals no. I will say that the application was built
so that if the fifth character is a zero, it will automatically default for you. So it will say scope equals no. The fifth character is a — the four, then it
will automatically default to scope equals yes. And this can be edited so
the scope field can be edited so the default section can be changed if needed. But we get questions about this,
and not everybody knows this. Okay, so let’s talk about some additional
fields required for specific procedures. There are four procedures for which
additional risk factors are collected. C-sections, fusions, HPRO’s and KPRO’s. When any of these procedures are
included in your monthly reporting plan, additional corresponding information
and fields must be completed. This is conditionally required so this means
only if the procedure was actually performed. Okay, so as you can see here, spinal level and
approach are required for fusion procedures. We do not have a CPT spinal
fusion approach guidance for this. CPT codes don’t lend themselves to this,
and they don’t have this level of detail. So this is just for ICD10 codes. How many of you here are
performing HPRO surveillance or KPRO surveillance in your facilities? Oh, a lot of you. Great. Okay. Wonderful. So I’m sure you are familiar with this,
but if the procedure is an HPRO or KPRO, you need to indicate here what
type of HPRO or KPRO was performed. Field for supplemental code
is not a required field. This is an optional code. Okay. So remember that you can
find guidance for these fields in the supporting materials
section on the NHSN landing page. Okay. So hang in there. You’re doing well. I think we might be even ahead of schedule. I’m a little bit of a fast talker so I
think what I want to do now is just get into definitions of surgical site infections and then I think we’ll probably break probably
midway through that so everybody can get up and stretch and take a nice break. So I think the monkey’s so cute. I don’t want to leave the slide. But I will. All right. So let’s talk about definitions
of surgical site infections. I will note that we have minor changes that
were made for 2017 to these definitions, very minor but I will note these as we go. Let’s start from superficial incision SSI. So what is the superficial incisional SSI? Well, it’s an infection that occurs within
30 days after an NHSN operative procedure where day one equals the procedure date and
involves only skin and subcutaneous tissue of the incision, and the patient
has at least one of the following. Purulent drainage from the superficial
incision, organisms identified from an aseptically obtained specimen from the
superficial incision or subcutaneous tissue by a culture or nonculture base microbiologic
testing method, which is performed for purposes of clinical diagnosis or treatment. Or superficial incision that is deliberately
opened by a surgeon, attending physician or other designee and culture or
nonculture based testing is not performed. To go along with this criterion C,
they also have to have at least one of the following signs or symptoms. Pain or tenderness, localized
swelling, erythema or heat. And then finally criterion D a diagnosis of
a superficial incisional SSI by a surgeon or attending physician or other designee. I want to note a few things
while we’re here on the slide. First of all, sometimes we have questions
about what would be for criterion D? Who really can make that call? So I just wanted to highlight here the
term attending physician for the purposes of application of the NHSN SSI criteria
may be interpreted to mean the surgeon, an infectious disease physician, another
physician on the case, an ER physician or a physician’s assistant,
nurse practitioner, what not. So for 2017, we removed the sentence
in criterion C that read a culture or nonculture based test that has a negative
finding does not meet this criterion. We feel now that this definition should
read more clearly and be less confusing. So I don’t know if you all remember that
just last year, but this is now removed. Hopefully should read a little easier for you. There are some reporting instructions when
it comes to superficial incisional SSI’s so the diagnosis of a treatment of a cellulitis
alone where there’s redness, warmth or swelling by itself does not meet criterion for
D, for superficial incisional SSI. Conversely, an incision that is draining
or that has organisms identified by culture or nonculture based test is
not considered a cellulitis. A stitch abscess alone where there’s
minimal inflammation and discharge combined at the points of the suture penetration
this is not considered an SSI. We will not consider this an SSI. A localized stab wound or a pin site
infection is also not considered a surgical site infection. And then note that a laparoscopic trocar site for an NHSN operative procedure
is not considered a stab wound. We would investigate this as
a surgical site infection. For a stitch abscess, note that this only
lives in the superficial incisional criterion. Remember that if multiple tissue levels
are involved in the infection that the type of SSI whether it’s a superficial incisional,
a deep incisional or an organ space that is reported to reflect that
deepest tissue layer involved in the infection during that
surveillance period. So now this is a screenshot that was taken
from table 2 from chapter 9 SSI protocol. It shows which procedures have
a 30 day surveillance period and a 90 day surveillance period. Remember, there’s 39 NHSN operative procedures. And note that superficial
incisional SSI’s only have — we only follow those for a 30 day
surveillance period for all procedure types. So if it’s a superficial incisional SSI, like
for example, let’s see, it’s a breast procedure. If they develop a superficial incisional SSI
outside of the 30 day surveillance period, then you wouldn’t count this because it
stops superficial — that stops at 30 days. If you try to enter a superficial SSI beyond
the 30 day period, you will get an error message that the SSI does not meet criteria. The application does have business rules built
into this. It’s smart, and it will pick that up. 90 days surveillance will only apply to your deep incisional SSI’s
and your organ space SSI’s. So for superficial incisional SSI’s,
superficial incisional primary and there’s superficial incisional secondary. Superficial incisional primary
is an event code option for all 39 NHSN operative procedure categories. But there are certain NHSN operative
procedures that also have the option of a superficial incisional
secondary event code. So what is a superficial incisional primary? It’s a superficial incision, incisional SSI
that is identified in the primary incision in a patient that has an operation
with one or more incisions. So for example, a patient that undergoes
a C-section or perhaps the patient that undergoes a — it’s a chest
incision of a coronary artery bypass graft where both the chest and
donor incisions were made. That’s your primary site, your chest incision. Now, a superficial incisional secondary, like
I said, only applies to certain procedures, and this is identified in the
secondary incision of a patient that has an operation with
more than one incision. So that would be your donor site for
your coronary artery bypass graft. That will be your actual — your leg incision. If they develop an infection
of that site, then that’s SIS. Now the appendix at the back of
chapter nine of the SSI protocol lists out every NHSN operative procedure and which
of these procedures has secondary sites. Really like this appendix, and I think sometimes
we get questions from users about is this — does this have a secondary incisional site? Well, it’ll actually outline it and
delineates that in the back in the appendix. Okay, let’s get into another case. On January 15, we have a 68-year-old
patient that had a colostomy takedown. So this is coded as a COLO procedure. On January 22, the abdominal ostomy
site has purulent drainage noted and the surgeon removed a few
staples and then probed the site. The surgeon did note that the fascia was intact. Should this be reported to NHSN? No. This was the old colostomy site,
and it doesn’t count as an SSI. No. This is a skin and soft
tissue infection and not an SSI. Yes. SSI is a superficial incisional
primary or yes, this is an SSI. It’s a deep incisional primary. What do you think? A few more seconds. All right. Let’s go ahead and see what
your thoughts are on this. Good job. 85 percent of you noted that
it’s a superficial incisional SSI, and it’s a primary — it’s an SIP. So you’re exactly correct. Let’s talk about the rationale for this. So this does occur so the infection occurs
within 30 days of the NHSN operative procedure. It involves only the skin and
subcutaneous tissues of the incision, and there was purulent drainage noted
from the superficial incisional level. Note that an infection of an old colostomy
site will meet superficial incisional SSI after a takedown COLO procedure. So this does meet. Okay, so let’s move into our fourth case. So on January 15 or January — this is February
15, we have a 62-year-old female admitted and underwent a total knee arthroplasty. So she underwent a KPRO procedure. She went home on February 17. She’s back so the patient is seen
on March 9 in the physician office after the patient tripped and fell at home. There’s drainage noted from
the superficial incision. A culture is collected from this drainage. The culture grows coag-negative Staph. What would be reported? Would it be a superficial incisional
primary attributed to the KPRO? Would it be a deep incisional
primary attributable to the KPRO? Would we report nothing because the wound
culture grew common skin flora only? Or would we report nothing
because this patient fell at home. Therefore, you cannot attribute
an SSI to this KPRO procedure. Few more seconds. All right. See what you think. Good job. 78 percent. It’s a superficial incisional
primary attributable to the KPRO. Let’s talk about this. So these are some questions that actually
come to us here at NHSN, and that’s why I want to address it because I’m sure some of you have
thought this but you just haven’t asked it. Common commensals like the coag-negative Staph,
they are not excluded from SSI determination. These are organisms and we do include those. So just — you may think oh, this is a
contaminant, doesn’t really mean much. No. These are included. But when there are culture results of
a mixed flora or mixed cutaneous flora, these cannot be reported to NHSN as there
is no such pathogen option in the drop down menu for a list of pathogens. Also, I want to discuss numerator
reporting number 12. An SSI that otherwise meets the NHSN definition
should be reported to NHSN without regard to specific postop accidents, falls,
intraoperative inappropriate showering or bathing practices or other occurrences
that may or may not be attributable to patients’ intentional or
unintentional postop actions. So those are still reported to NHSN. Unfortunately, something may have occurred,
but if a patient decides that they get like a hip replacement and then ten days
later they’re hanging out in a hot tub, and then they end up with a surgical site
infection, we aren’t just going to say, no you don’t need to report it to us. You have to report this to us. So those will not — will not
discount the fact that it actually ends up being a surgical site infection there. Okay. So let me get going I
think on deep incisional SSI. I may — I may — well let’s see how far we
get, but I may or may not stop in between to let us — to let you all out for a break. Okay. Deep incisional SSI, there were no
changes for 2017, for these definitions. Let’s review what a deep incisional SSI means. Okay. So a deep incisional SSI is an
infection that occurs within 30 or 90 days after the NHSN operative procedure
where day one is the procedure date and involves deep soft tissues of the incision. So it’s going to be the fascia and
it’s going to be the muscle layer. And the patient has to have
at least one of the following. Purulent drainage noted from the deep incision,
a deep incision that spontaneously dehisces or is deliberately opened or aspirated by a
surgeon, attending physician or other designee. An organism is identified by a culture or
nonculture based microbiologic testing method which is performed for purposes of
clinical diagnosis or treatment for culture and nonculture based biologic
testing method is not performed. And the patient has to have at least
one of the following symptoms or signs. Fever, localized pain or tenderness,
a culture or nonculture based test that has a negative finding
does not meet this criterion. So if you — let’s say the patient has a deep
incision that is deliberately opened and then if they culture that deep layer so they culture
the muscle fascia layer and it’s negative, even if they have a symptom to go
along with that, it’s not going to meet because they actually went there. They cultured and it’s negative. Now if they don’t culture it, they don’t
even — they just get in there, there’s pain and they deliberately open it, it’s going
to meet because they didn’t culture it. We don’t know so we can’t say. So it will meet. Also criterion C is — and we don’t see this as
frequently but this can apply that an abscess or other evidence of infection involving
the deep incision that is detected on gross anatomical or histopathological
exam or imaging test. I think that’s key there, criterion B.
Remember, that if it’s culture negative, you cannot apply criterion B. It has
to be at that deep incisional level. So here just like superficial incisional
SSI, deep incisional SSI also have the option of a deep incisional primary and a deep
incisional secondary incision event codes. I explained what this was for the superficial. Same rules apply for the deep. Only certain procedures for deep incisional
have deep incisional secondary sites. Remember refer to the appendix
at the back of chapter 9, the SSI protocol for these particular
procedures and what have secondary sites. Okay, so I am going through cases right now,
and I wanted to stop right here to just mention that as I work through cases with you, I
want to point out exactly what NHSN needs from you the user for a complete
NHSN case review request. If you are sending NHSN an SSI question, it
really helps to provide us with as many details as possible to help us best
guide you with the case. This may help in the long run because it’s going
to decrease the amount of back and forth emails in turn providing quicker response time for you so you know exactly what
to do with that scenario. It also helps us to get your
thoughts regarding the case and a feel for what direction you may be going in. And the reason I wanted to bring this up
is because sometimes we’ll get questions where there’s going to be a lot of back
and forth emails between us and the user because maybe the user doesn’t know what to
ask so we thought we’d put something together to maybe help you as the user to gather your
information, to provide to us here at NHSN to help work through that case with you. So perhaps really a question for us may be this
is a complicated case and our team is trying to figure out whether it meets
criteria for deep incisional SSI. Can you help us confirm this? So what NHSN may need from you as the
user, these are all things to think about as you’re looking at the case and
you’re trying to figure out what’s going on. So if it’s an SSI, all the OR
procedures and all the dates for these procedures including knee reoperations
dates particularly it’s helpful for us if you put them in order whether
these operative procedures are coded as an NHSN operative procedure or not because
a lot of times you’ll hear back from us and be like is this an NHSN
operative procedure not? What’s the code? Let’s start there first to
see what we’re working with. If it’s a return to OR via the same
incision, was it within 24 hours of the finish time of a prior
operative procedure? What were the signs and symptoms
noted with that patient? And then also what tissue
levels may have been involved? Was it just localized to the superficial level? Was it down to the deep incisional level? Or was it organ space or maybe it was all
the way from superficial to organ space. Was there any imaging testing
performed and described? Provide this if you can. Were there fluid collections
or any drainage noted. So maybe CT guided drainage was performed. There was drainage from a JP drain. There was drainage noted from a wound. Was it purulent? Was it serosanguinous? How was this drainage described? And any culture results that you may have. What site was the culture collected from? And then what tissue level was
this tissue collected from? Sometimes the cultures are labeled
in a way where we do not know where they collected that culture. I mean, I’ve seen it and
then you’re trying to figure out exactly what are they talking
about or how deep does this go? So sometimes instead of just ignoring that and
just trying to work off of that, you want to — you may have to go back to the surgeon. You may have to go back to somebody involved
in that case to probe a little bit deeper and see exactly what happened there or
where was that culture collected from? Any other evidence of infection that you may
have that you may feel that might be pertinent for us to know to help you in
determining what to do with that case. So I wanted to note this here. These are some points to help you as you’re
working through cases, and it helps us and then we can get answers back
to you quicker and we’re all good. So let’s move on now to case 5. So November 1, the patient is admitted
to the hospital for an HPRO revision. At this time, there’s no evidence of infection. On 11/4, the postop course is unremarkable
and the patient is discharged home. On 11/18, we have a patient
that is admitted with complaints of pain and swelling since 11/16. The patient now goes to the
OR for a left hip I and D. And serous fluid was cultured
from the fascial layer. On 11/19, the culture result returned and is
positive for Staph epidermidis in broth only. Is this an SSI? Yes, this meets criteria or no the
culture was grown in broth only. Okay. A couple more seconds. All right. What is this? Yes, this is an SSI. This meets criteria. Good job. 96 percent. That’s great. I’m proud of you. What infection should be reported? Do we have a superficial incisional primary? Do we have a superficial incisional secondary? A deep incisional primary or
a deep incisional secondary? Do we have an organ space PJI? What do you think should be reported? Okay. A lot of responses. Let’s see. SSI, deep incisional primary. Great job. 78 percent. Let’s talk about the rationale
for why this would be this. First of all, it occurs within 90 days because
we know we follow these procedures for 90 days. They have a 90 day surveillance period. It involves only the deep soft tissues
of the incision so it’s the fascia and the muscle layers were involved. And it was deliberately opened. And organism is identified from the fascial
level, and the patient is also noted to have localized pain so you meet deep
incisional criterion B. You have swelling. You have pain, redness and a positive
culture from the fascial level. Specimens from growth media
only, broth for example, are not excluded from NHSN surveillance. Broth only positive cultures are
considered a positive culture result and treated as such for surveillance period. Such media can be enriched to identify
organisms that might otherwise be missed. So we do get this question, and I
wanted to note that these are included. Okay. So this is a different
scenario same patient. November 1, the patient is admitted
to the hospital for an HPRO revision. November 4, the postop course is unremarkable. The patient is discharged. Now, on November 18, the patient
is readmitted with complaints of pain and swelling since November 16. They are off to the OR for a left hip I and D.
Serous fluid was cultured from the fascia level and then on 11/19, the culture
result returned negative. What infection should be reported? This is superficial incisional primary, deep incisional primary, an
organ space SSI or nothing. This does not meet SSI criteria. I know there’s more clickers out there. All right. Let’s close this out and see
what should be reported here. Good job. Nothing. Does not meet SSI criteria. 88 percent of you indicate nothing. You’re absolutely correct. Let’s talk about why this is. First of all, we do meet
in that the infection occurs within the appropriate surveillance time frame. It involves the deep soft
tissues of the incision. But even though there was pain and a deliberate
open of the incision to the deep fascia, because the deep incision was
cultured and it was culture negative, this does not meet deep incisional SSI criteria. Remember that criterion B, deep incisional? We cultured it at that level. It’s negative. It’s not going to meet. Okay. So we have case 6. On 12/15, we have a 55-year-old patient who underwent an extended right
hemicolectomy COLO procedure. On 12/20, the patient is discharged home. On 12/28, the patient presents to the ED
complaining of abdominal distention and pain. A CT of the abdomen and pelvis show
a postoperative fluid collection. The patient returns to the
OR for an XLAP procedure. The surgeon evaluated the
intraabdominal fluid collection. Fluid collection was drained. There was no mention of purulence
or infection noted at the time of the fluid drainage and
no cultures were collected. It might be a little bit trickier but let’s see. What infection should be reported? Is it a superficial incisional primary, a deep
incisional primary, an SSI organ space IAB, an SSI organ space GIT or is there no SSI here? It’s okay. I mean, it takes a little — it’s a
little bit of a trickier question. But — All right. A couple more seconds here,
and then we’ll close this out. I really want to get 70 responses. Come on. One more. Okay. Okay. So no SSI. Good job. It’s a little bit all over —
it’s a little bit more up and down here, but that’s okay because it
might be a little trickier. So what SSI — this is not an SSI and
let’s talk about why this is not an SSI. And there’s a reason here
I want to discuss this. This was — this does not meet deep incisional
SSI criterion B because the reason — the only reason they opened the incision is as
an approach to get to the area of real concern which is actually the organ space. You cannot call an infection at a lesser
level unless it fully meets the criteria. So if a surgeon deliberately opened an
incision and the reason why they wanted to get to the organ space perhaps there
was a fluid collection noted. Then you cannot — the deep
incisional criteria cannot be met because they didn’t deliberately
open it to stop it deep. They wanted to get to that organ space. This is important because sometimes
users want to just back track and state well it doesn’t meet
organ space SSI, can I just back it up and call it a deep incisional? No. It actually has to meet
it for the right reasons. So it seems a little bit trickier, but we
do get this question sometimes so just note that you kind of got to get a
feel for why exactly they went in and really — where they probing to? To what tissue level? And why? So hopefully it wasn’t
too hard, but nevertheless — so I think what we’ll do here now is we’re going
to stop and take a break because we’re just about to get into organ space SSI
criteria and so go ahead and take a break and then meet back here I would say about
9:45’ish and then we’ll go ahead and finish out the rest of this presentation. So thank you.

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