Surgical Site Infections (SSI) Surveillance with Case Studies (Part II).

Surgical Site Infections (SSI) Surveillance with Case Studies (Part II).


>>I had a few good questions during the break. Even though we still have
another hour — two hours. I’m going to present for another hour and
a half and then Maggie’s going to come back and present on how to export data. But, I did want to give you two points —
because one which I might not come back to. If a patient has a — you get their ICD-9 codes
back and what you see is two colo codes — different codes, but they’re
both in the colo group. That’s one colo procedure. Do not put in two colos. That’s true for anytime you see multiple
ICD-9 codes that fit into these same NHSN and operative procedure codes,
that’s one procedure. They just happened to do two
things that both met colo criteria. And again, I am a broken record, I know. That is in your denominator
reporting instructions. Okay, so let’s go ahead and get started. So there are a few procedures that have
some additional fields that you get to have to put some denominator data into. And there’s five procedures,
that if you’re following these in your reporting plan, there’s extra fields. That’s C-sections, which have
been true for quite a while, your fusions/re-fusions, H-pros and K-pros. All of these have a little bit additional. So for C-section you’re going
to need to put in the number of hours they were in labor in the hospital. The length of time from beginning of
active labor as an inpatient to delivery of the infant, expressed in hours. And if it’s less than 30 round
down, greater than 30 round up. If there’s no hours of labor, like a
planned, elective C-section, it’s zero hours. And you just need to check for
documentation in the chart. And this can be defined as active labor, but
however your hospital policy is doing it. We don’t micromanage this data field,
but it is something you’ll need to know. Fusion/re-fusions have, again, two areas. The first one is you’re going to tell us at what level the procedure
was done and then the approach. And some people have said, “Oh, what
if it’s anterior and posterior?” Remember we have a field
for anterior and posterior. When they’re both done, you’ll put that in. And if they do it at a multiple procedure
level, if it somehow ends up actually crossing into atlas axis and atlas axis cervical. You do the area — choose the area that
had the most number of vertebrae fused. And in our — because I just
answered this recently. People say, “Well how do I know which this is?” In our table of instructions,
again, broken record. We have the exact different
spinal-level cervical vertebrae named. We say, you know, with atlas axis goes these. This through this, this through this. So we really tell you exactly
which vertebrae are included in these groups in the table of instructions. We don’t have unknown anymore. If it’s unknown or not listed, you’re going to
need to obtain information for that procedure, you know, and usually you’ll have to
just read the op note and they’ll say it. If they didn’t, I would just really
base it on what the ICD-9 code is. Some of the ICD-9 codes will actually
say this is a cervical fusion, if they didn’t note it you can use that as well. We used to have a lateral transverse
code, and that got replaced by trans-oral. Because it’s more the terminology. If you actually go into the
current ICD-9 Code Book, you won’t find that lateral transverse listed,
it’s now — you’ll find trans-oral approach. All right. Forgot I had all these popups,
but I’ve told you all that. All right, now hip arthroplasties and K-pros. H-pros and K-pros have some additional fields. They’ve always had additional fields,
and they have a few more this year. I do want to get a show of hands, how many of you are reporting H-pros
and/or K-pros right now? Huge number, wow, okay that
— 90% it looks like. So, I mean that’s a very high number. I did not expect that. Okay, so I may spend a little more
time on these next couple slides. And I will tell you this is a little confusing
right now with ICD-9 codes and so I am going to just open myself to saying please,
if it doesn’t make sense here, you can send me questions in the NHSN mailbox. So, what we did. We provided this for you. One of the sort of experts here
at CDC is a orthopedic surgeon. And she was really, really sweet, because
I said, you know what, “We’re IPs, we’re not surgical nurse, we’re not orthopods,
sometimes when someone says it’s a total — total primary, like what does that mean?” So this is her best at — can
you put them in little, tiny, short sentences of when we’re saying something’s
a hemi-partial revision, what does that sort of mean in just easy lingo to understand. So I think — I’ve shared this with
a couple people via the mailbox and they’ve found this to be very helpful. So I’m just providing this sort of real life
language of what these mean for you, okay? And there’s also some really good resources
that she included that she thinks if you want to know more about what hip resurfacing means,
she put in a link for that — hemis and totals. So she was very sweet to
provide this information. Now for K-pros she did the same thing. Gave some good resources for us to use and
kind of gave a description of what this means when you see someone’s had one of these. And again, you all could have probably gone
to your orthopedic advanced practice nurse, you know, that you have and gotten something
similar, but I wanted to provide something. So, because we had these fields and
people were like well, what ICD-9, you know, how do I know what this is? So if you’re manually reviewing, you can
read it and try to put it together yourself, but if you’re using ICD-9 codes, we
provided for this because it was confusing. And this came out in a newsletter. It’s in your Alls Newsletter Box. We provided a mapping tool,
if you were using ICD-9 codes to help you just select these
boxes you’re going to see based on what the ICD-9 code that came across. So unfortunately, manual chart review,
or direct entry into the OR database, would be required to correctly specify these for
the H-pro and K-pro can be difficult due to — and this is the keyword, the lack
of specificity of ICD-9 codes — CM codes they just don’t map
one to one — they don’t. And if you could really tease out and read in
detail every op note, maybe you could figure out what they’re doing, but everybody
doesn’t have the ability to do this. And the good news, from everything
we’ve heard is that ICD-10 PCS coding is much
more granular and more specific. And hopefully we won’t have a thing where — yeah, every .00.81 to 00.84 is a K-pro hemi
partial revision, so we’re going to see. So what we did, is we’ve told you these
are your K-pro fields and if you find, and you want to use ICD-9
codes, if you find an 81.54, you will call that a total, total primary. Okay because you have to first
click total, then total primary. And, you know you can see all these. And if you find anything
that’s a 00.81 to 00.84, that’s a hemi partial revision,
anything in that code. So we’re hoping that these will help you, and
this is in an NHSN newsletter that was sent to everybody just for this mapping. And you should be able to
find it in your mailboxes, when — if you forgot to open that one. I know we get busy. We did the same thing for the H-pro mapping. These are the different possible
fields that you could use for ICD-9 code mapping for
these new required fields. And you’ll see them all listed here for
the resurfacing, the hemis, the totals. Now this is where this orange
note, I want to give you a note and this will make a little more sense, I think when Maggie then talks,
if you’re using CSV files. Due to a defect that we’re going to be
correcting when NHSN goes from ICD-9 to ICD 10s. That 00.71 and 00.73 — see they’re
in this hemi partial revision? They really are hemi partial
revisions, those codes. If you are putting — uploading this via like
a CSV file, or you’re entering ICD-9 codes, when you go to import that, you’re going to get
an error message that that code doesn’t match for a hemi partial revision,
but it is how we want it coded. So 0071s and 0073s we prefer you don’t use
an ICD-9 code for those and just name it as a hemi partial revision, okay? Then you will not get that error message. And it’s all here, you know, it just says
leave that code field blank and just select that it’s a hemi partial revision. Just for those two codes. And this will all go away and be
fixed when we go to ICD-10 codes. So in summary, complete and enter — or
import a denominator for procedure record for every NHSN operative procedure that’s
performed and selected for surveillance. Use the SSI protocols, your
table of instructions, key terms, and chapters from the Patient Safety Manual. Now, we’re going to go briefly
to linking a procedure. So you’ve gotten all your denominator
data in there for the month. And now you’re doing spectacular surveillance
and you’re out there finding your SSIs. And you want to link these two together. It’s basically telling you, this
denominator, this procedure done on this day, I now have an SSI on this day. And as Maggie said, it’s procedure-based. That SSI may have occurred in March,
the procedure was in February. It’s going to show up as a February infection. If it’s linked to that in
terms of your SIR and analysis. Even though — because that’s the
denominator, is the day you do the procedure. Linking is really important because
it gives you the correct risk factors that were matched very specifically
for that SSI. So all those risk factors are in there. So first you enter the denominator. You don’t want to put in an SSI if you
haven’t gotten your denominator data in yet. If you found the SSI for some reason
and you haven’t done any of your — just hold it back for a little bit and
make sure you’ve got your denominators. And then you’re going to enter the SSI
record and you’re going to link the two. Now this is something I really want
to emphasis how important this is and it will make your life easier
and you will get less error messages, because I made this mistake
many times as an IP myself. If I forget and I start going, “Oh I got
my SSI, let me start entering all my data,” I enter it all and then I say
I’m going to link this procedure and I get this big error,
“That procedure is not found.” And I’m like, wait, I know I put
that procedure in, try again, still. You don’t want to enter any of
your SSI data into this, okay? Just get the patient’s name, link an event. You’re going to put in that you have this SSI. See all I have filled in here [inaudible] is
that there’s an SSI, and I’m going to link it to the patient’s — you do
have the patient’s ID up above. And then when you link it you’re
going to click that button, okay? And then it’s going to send you to
the procedures that patient’s had. Don’t put any more in than that. You’re going to select this
procedure next to the colo and you’re going to hit that link button. And then when you go back, it’s going
to send you right back to that record. And it’s going to have filled in
the stuff that you put in before. Because if you have the tiniest little
mismatch from what you put in there in that denominator data from something
you go forward and put your numerator. You’ll get that error message that we can’t find
that procedure because they don’t match exactly. That will help you a lot. See there you go. And then it auto-filled this. And now all the data are linked
together and they’re exactly right. They’re not mismatched at all. And then you click — don’t
forget the save button. Now we’re getting into the meat of it. People will come up and will
ask me like, when are you? I said no, we’re going to cover the SSIs next. So now. Superficial SSI this — because
you are — very few of you are brand new, I am not going to read every definition. I’m going to highlight the issues, the concerns
that happen and point out what’s different. So remember colo and hyst procedures
are both 30-day procedures. So for those — they never go beyond that. And I want to tell you something,
because I was giving a training for some of our state health departments
a couple months ago. And they are finding facilities that think
because CMS just get our deep, incisional, and are organ-based infections that they
can completely blow off superficial SSIs and not look for them, not report them. Well when you look at when you do when you agree that you are an NHSN facility,
and you have your certificates. You agree — when you sign up to do
something that you’re following the protocol. So you are supposed to be doing
superficial, deep, and organ spaces, just that we only send the
deep and organ space to CMS. But there was never anything that
said don’t look at superficials, at least not at this point, we
haven’t gotten rid of that definition. And we did not really change
anything with superficial SSI, except it is the only definition that still
has diagnosis of a superficial incisional SSI by the surgeon, and you’ll see that that
was removed for deep and organ space. Now this is a new — let me,
I want to go back one more, I want to get to that — I get to that layer. So this is the newest reporting instructions. Someone asked me about this
before the lunch break. This has really been simplified. So in the past we had a lot
of little funny rules. If something is a deep, if it meets
superficial deep and organ space, you should split the difference
and call it a deep. If something is a superficial and organ space, and you actually find the
organ space is draining through the incision, then you call it deep. And there were a lot of little
funny rules about splitting. We got rid of all of those. You simply call the infection at the deepest
level that it actually went to within — this is the keyword, within the
appropriate surveillance period. So if you write a superficial SSI up on day 20,
after a hyst and then the patient comes back in on day 40, and it’s progressed
to a deep, you do not upgrade that. You did not meet the definition
of a deep in surgical — a deep incision in the 30
day surveillance period okay? That really drives everything. If you try to enter a superficial
SSI beyond the 30-day period. This is where we talk about the
application, the business rules behind things. We try to make the application — some
people have been asking about validating, how do you know it’s the right data? You’re going to get an error
message that says this. Because you’ve already said
you’re sending us a superficial. And if it’s beyond the 30-day period,
you’re going to get an error message and it won’t specifically say — tell you why, but it’s going to say it
doesn’t meet definition. So stop and look. Because sometimes it just falls off our plate. You know, you’re busy. It’s like oh I didn’t even notice this was day
35, that’s why I’m getting that error message. All right? Now, I do want to point out — look next —
here next to the 90-day surveillance period. This is just cut from the protocol. Over here, you’ll see the note
at the bottom of this page. This is table three from our manual. Superficial incisional SSIs are only
followed for 30 days for all procedures. This is another question we get. Someone will be reporting. They’ll say, oh, here’s my 90-day
surveillance categories, okay? So we have — We got rid of implants. Remember back in 2012, if a patient had a — yeah [applause], you guys are still
happy — you’re still happy about that. Remember back in 2012 you had to look for every little internal staple
and implant followed for a year. That went away in January of 2013. So it doesn’t matter if they used
an implant in that procedure or not. You can breasts are in the 90-day
surveillance period and the breast with an implant, the breast without an implant. They’re all followed for 90 days. But this note down here is
telling you, no matter what. For all of these categories, superficial
is only ever followed for 30 days. So I’ve had people really get confused,
because they’re ending a superficial SSI on like a breast procedure and they
know that’s a 90-day procedure. And they don’t understand why. You’re going to get that same error message
because you can only report the superficials. It’s the deep over here and the
organ space that you can follow for the beyond 30-day and up to 90-day period. So a couple little reporting
instructions for superficial SSIs. Do not report a stitch abscess. Now I’m going to define stitch abscess because
I have had some surgeon notes copied to me, where you’ve got a person with
their huge abscess in their muscle, and they say, well that’s where a stitch was. I’m like nah, nah, nah. That’s not what we mean by a stitch abscess. We mean. And I’ve, you know, I’ve had some
personally myself, it’s where the suture, the staple enters the skin and
you get a localized little abscess at that external lateral position. That’s what we define as a stitch abscess. Those should not be reported as SSIs. They don’t meet our criteria. Also, don’t report a localized stab wound. Now someone asked me, they thought
this meant like from a street fight. I’m like no [laughter]. Those might get infected,
but they’re also done as — no we mean when they make a stab wound
to put in a JP or something like that. That’s what we mean by a stab wound. So if you have a — they have done
a stab wound to insert a drain and you get a localized infection
of the skin around the stab wound. That is not an SSI. Now if you’re Pennsylvania, they must
feel like we’re picking on them by now, that could become a skin soft tissue, you know, just non-SSI skin soft tissue
infection, it may meet. But it shouldn’t be reported as an SSI. And that’s what I say there. And the last one is a little
messy, but it’s cellulitis. So here’s where we go with physician diagnosis. I’m going to give you two
examples of physician diagnosis. You have a patient that literally — let’s flip back to our definition
of a superficial SSI for you here. You have a patient who comes in, and
the only symptoms they have are redness, and a little redness and some warmth. That’s it. It’s looking a little angry. But that’s all you’ve got. That’s a cellulitis. There isn’t drainage coming out of it. The surgeon isn’t opening it and doing
anything fancy, you’ve just got that. The physician calls this SSI and treats them. That does not — what supersedes is the fact
we don’t want you reporting cellulitis alone. So if a physician treats a cellulitis, that doesn’t mean you now do criterion
D. We don’t want you doing that, that’s a reporting instruction. What we would have to report, and they
say, “Well what would we have to report that the physician would call an SSI?” You could have a patient who has a lot of serous
drainage coming from their superficial incision. Look at this, A. It’s not purulent,
but it’s really a ton and it’s serous. And the physician calls that
an SSI and treats it. This is where a physician
diagnosis would come in. You would call that, and you’d use criterion
D. We don’t see it having to be used a lot because usually they’ll meet
with some other reason, okay? The other one I want to talk about. Oh man, I hope I can finish this, I’m
going to have to start talking fast, is I get a lot of questions of what do you
mean by an aseptically obtained culture? Basically, if that culture arrives to your lab,
or the lab that you use and that lab accepts that culture, and that culture comes back with
a known — with an actual organism identified. It isn’t mixed skin flora, it isn’t mixed
flora, it isn’t mixed cutaneous flora. It has an organism in it. You assume that your facility obtained that
properly following proper policy and procedure for how your lab and your
facility wants wounds collected. If you think your facility is not following
proper technique for collecting wound cultures. That’s an educational opportunity. But you can’t just look at things and
say, “Ah, I don’t like how that looks, I don’t think that was aseptically obtained.” That’s not your call. This is the — you have to trust
that your lab runs proper specimens, the ones that weren’t properly
obtained should be coming out as mixed cultures and just a bunch of junk. And those don’t meet our criteria, okay? So I won’t address that. And then the last one I want to address — and a lot of people really get this is the
criterion C. So you could have a patient who comes in with a really
red, hot, angry looking wound. The surgeon wants to know what’s going
on underneath it, or the surgeon wants to know what’s going on underneath
it, or the ER physician. And they actually open the wound. It is deliberately opened. This is no spontaneous dehiscence in here. And they deliberately open
it, remove a couple staples. And a bunch of stuff drains
out, they poke around, they look, and they do not get a culture. They say, “I’m not culturing it, I’m just going to open this thing up, and
drain it, and do whatever.” If that patient came in with these wounds,
pain, tenderness, swelling, a hot — there’s some reason that physician
decided to open up that incision, and they choose to not culture, this will
meet criterion C. If they do that same thing and they get under there and they’re like
“Oh, I think this might be a seroma,” and they culture it, and it’s
culture-negative, you don’t meet this criteria. A culture-negative finding
does not meet this criteria. If they get in there and there’s this icky,
thick black-ish looking stuff and it looks like it may be an infected hematoma,
and they open it, and they drain it, and they send a culture, and it’s
positive, that’s an infected hematoma. I get that a lot. Is every seroma infected? No. Is every hematoma infected? No. But this is how they’re
often found, is right like this. So I just want you to be
clear on that no culture done versus a negative culture, versus a positive. And spontaneous dehiscence, which will show up
in our deep incisional, doesn’t show up here. And I think it’s actually because
there’s a lot superficial incisions that will spontaneously dehis a little
bit, you know, they’ll have some issues, but we do have spontaneous dehiscence in deep. Because you really don’t — if a deep wound,
for it to spontaneously dehis to the deep level, that’s a major thing, versus a little
superficial dehiscence, which is what we’ll — so, but for the superficial, it has to be deliberately opened to
meet that specific criteria. All right. So you can have both, a superficial
incisional primary. I’ll use the CBGB’s as an example for that. The CBGBs, that if your chest
incision gets infected, that would be a superficial incisional primary. If your leg incision gets infected,
that’s a superficial incisional secondary. We only have a handful of procedures
that have two separate sites setup, but you’ll find that in your dropdown menu. You’ll be telling them, am I
writing up the SIP or the SIS? Okay? And so that’s what
you would do with those. And if a patient has both and they develop
an infection of their chest site, way up here and they have an infection of their
leg site, you’re putting in two SSIs. They’ve got a SIS and a SIP. So here’s an example I’ll get you. This is not in your clickers,
it’s just follow along. Patient delivers a baby by C-section on
August 23rd and on her first postpartum visit to her surgeon on the 20th, she noticed yellow,
purulent drainage in the superficial incision. Does Gretchen have a surgical site infection? I’m hearing lots of yeses. Yes. That’s purulent drainage
that’s criterion A. Okay. Is it a superficial SSI? At this point, from the knowledge
we have in front of us, yes. It’s from — it’s just purulent drainage
coming out of that superficial incision. Is this a SIP primary, or is it a SIS secondary?>>SIP.>>SIP. You guys are good. It’s a SIP. She didn’t even have — a C-section
doesn’t have a secondary site. So here’s another example. If a patient underwent a coronary artery bypass
graft CBGB, the surgeon got the donor vessel from a site in the leg, five days postop, the
patient has pain and edema in the leg incision. They open the superficial incision,
drain the pus, irrigate the wound. Does this person have a superficial
incisional SSI? Yes. Is it a SIS or a SIP?>>A SIS.>>Right, the secondary site, SIS. Let’s do another little case. You’ll need your clickers for
this, so share if there’s someone who hasn’t had the chance to use it. So, 2/18 you have a 45-year-old male admitted and he had a laparoscopic left
hemicolectomy, that’s 1735 and that’s a colo. Three trocar cites were closed and the
fourth site they used to place a JP drain. Then on 2/24, that’s about a week later, you have purulent drainage noted
at one of the trocar sites. The culture is obtained and it’s positive
for Enterobacter species and E. coli and the patient is started on antibiotics. Is this procedure considered
a primary closure for 2014? Got some voting going. Ten seconds, you guys are
so fast with those now. Yes. It is. Remember you’ve closed all
those trocar sites were closed. And if you have someone, I’m
going to just tell you this. I’m not sure it’s as clearly expressed
in our current manual as it was in ’13. If you have someone who has four trocar sites
and they close three of them and leave one open and they just don’t close it — you still
have a — if any of multiple incisions, when you have a procedure that has multiple
incisions, like a laparoscopic procedure, if one of those is closed primarily, it’s
considered a closed — operative procedure. Primary closed. Very good. Case five, the rationale they’re using
for this one, the surgeon was just using that existing trocar site to place the JP
drain, rather than creating another stab wound. And if there’s multiple incisions
and one of them is closed primary, the whole procedure does meet criteria for
a closed — primarily closed procedure. What should be reported to NHSN? Well nothing in terms of — that, you know, the surgeon did not open the
wound, so the criteria not met. Nothing is an SSI, but not an HAI. It should be a superficial incisional
primary, or a deep incisional primary. You can look back at the case. Give you about 10 seconds. Lots of votes coming in. All right. You guys are good. Superficial incisional primary. And I’ll show you. We’ll go through this so you can see why. It happened within 30 days. It was only the skin and
the subcutaneous tissue. And you had purulent drainage
at that trocar site. It was superficial. And there was an organism that was
cultured, obtained, and was positive. So a lot of times you’ll meet more than one
criteria in an SSI definition and that’s fine. It’s not like when you go to enter
it, it’s asking was this A, B, or C. It just — it will meet criteria. Let’s try another one. Let’s go on to something
that isn’t a colo or a hyst. So this patient has a hip arthroplasty,
especially because all of you — so many — almost all of you are following hips or knees. And it’s performed on 3/17 at hospital
A. They get discharged on 3/19. That’s pretty darn fast, but
they get them out quickly now. They’re readmitted to hospital B on 3/25 with
purulent drainage from the superficial incision and further investigation
at that hospital concludes that this is a superficial incisional SSI. What should hospital B do? This is not clickers — this
is just [Background noise]? Exactly. They need to notify
hospital A about the SSI and give as much information as they can. And what should hospital A do? Exactly. They need to report that SSI to NHSN
if it’s in their hospital reporting plan. Hospital B doesn’t know if hospital
A is following H pros or not. Give them the chance to know this happened. And they’re going to report it because they’re
the ones you have to think it’s procedure-based. They’re the ones that have
it on their denominator data. I get questions from rehab facilities and
stuff saying, well they were fine when the left and then they went to rehab
and now they have an SSI. That doesn’t seem fair that I have to count it. I’m like, well the rehab can’t count it, they
don’t have the denominator data and it wasn’t — again you have to kind of get your brain
around that this is very procedure based. What if the same infection, this
H-pro met criteria on day 35? Postop day 35? What would you do? Right. It’s not an SSI. They have an infection, but it doesn’t
meet SSI criteria and it’s not reported. They’ve been gone forever, you know, they’ve
been gone for over 10 days from your facility. You don’t — it isn’t anything at that point. SSIs are always associated with that
particular procedure through linking. And if you don’t have that procedure in your
database you can’t link that infection to it. And you only follow your
superficials for 30 days. Let’s try case seven. So this is a 70-year-old male who was admitted
on 3/10 and underwent a hemi-colectomy and a repair of an abdominal wall hernia, via
the same incision on the day of admission. The incision was closed, and a JP was placed
via a stab wound in the left lower quadrant. And the patient went home about
four days later on the 14th. Then three days later that patient arrives
to the ED, has a red, painful incision. The incision is draining yellow, foul smelling
discharge from the superficial incision. The physician removes two staples,
we see these cases all the time. Probes the wound. The fascia is intact and there’s
only subcutaneous tissue involved, and no cultures were obtained. Antibiotics are ordered, the wound is packed
and the patient is discharged home from the ED. Great, you’ve seen these cases. This is — definitively we see these out there. So what should be reported to NHSN? Nothing, the wound culture was
negative, so it doesn’t meet criteria. Nothing. He had two procedures, so you
don’t know which one caused the infection. Valid point. It should be an SSI SIP attributed to the colo. It should be an SSI DIP attributed
to the hernia. All right, start those buttons going. A little tougher one this time. I’m sort of testing you on
something I haven’t taught you yet. But you guys are very experienced
so I’m sure you’ll get this. All right 10 seconds. I’ve got almost most of the responses. Finish it up. All right. Let’s see how you did. Oh, my gosh. Look at you guys. All right. Okay. There was only maybe
one person that said one. And one said two. Okay. It is correct. This is a superficial incisional primary
attributed to colo and here’s why. Because we’re going to go over that now. If more than one operative procedure
is done through a single incision, first attempt to determine the procedure that
is thought to be associated with the infection. So for example, here’s where one you could. The patient has a CBGC so just, you know,
and had a CARD done at the same time. And they come back with a valve infection. You know, it’s an organ space valve, then
the SSI should be attributed to what? The CARD. I mean you can tell sometimes
when you’re dealing with organ space which is the culprit so-to-speak. If it’s not clear, which is really
the case, almost really is the case with any incisional SSI superficial or deep,
you’re going to use the NHSNs principle after procedure selection list to determine
which of those procedures is higher risk for getting — because we’ve looked at this. We’ve said which procedures? And we re-baselined that list last year. And it changed things around
quite a bit when we did that. So there’s five lists that are in
table five, this is table five. You have your abdominal operations
linked all together, your thoracic. We combined neurosurgical
operations of the sprain and bine — spine and brain together this year,
because the risk worked either way. So it didn’t make sense to
keep it a separate list. It won’t change your data. They lined up exactly. It just was kind of confusing
to have them separated. And the neck. And the categories with the highest risks
are listed above those with the lowest. So we use this a lot. So if you look at this, that person
that had a colo and a hernia. Well hernias are way down here and the
colo is way up here and it was incisional. So this would be attributed to the colon. Man, I think I had something with lunch. Okay, let’s do deep incisional SSI. And for this one I put a little posted note to
remind you of the only thing we tweaked on this, the same thing you’ve been looking
at for the past couple years. Is that we did remove MD
diagnosis from deep incisional SSI. Okay? So, you’re going to
need to meet this criteria. So, and again the thing — this is pretty clear. Purulent drainage, but again
remember, we want them to be saying that this drainage is coming from the deep area. That means, they somehow have enough knowledge. And often it’s because they’ve had
to open it, that this infection is down in the fascia muscle layer, or that —
now for here you can spontaneously dehis, but what they’re saying again, the
key word here is a deep incision. So when it opens up, they’re
like seeing the fascia muscle. It really opened up. It was a bad dehiscence. Or it was deliberately opened. And this is the same again. And it is culture positive. Or they chose — now this we see more rarely. If it’s to the level that a person’s literally
— they’ve opened up to the deep level. A lot of times they’re back in the OR. But they’re usually — they
culture to see what’s going on. And you do have to have some kind of symptoms
here, but fever, and it’s just localized pain or tenderness, and a negative culture,
again, will not meet this criteria. So it’s very, very similar to superficial. But here, you can have a spontaneous
dehiscence or deliberately open. And the last one is that they
just really observe in that area, the deep incision on direct exam. Means the physician looks at it and sees what
looks like an abscess purulent fluid, whatever, in the deep area during an invasive
procedure, or by histopath or imaging. So the invasion procedure here could be that
they actually take the person down to CT, doesn’t mean they have to go to the OR, and
they drain an abscess that appears when it — based on the imaging they did
of it and when they go down, that this is still localized
to that muscle fascia level. Okay? Very similar, you have
the primary and the deep. Primary infections or secondary
sites, exactly what we just talked about for superficial, pertains to deep. Let’s try another case. So you have a patient is admitted to the
hospital on 3/12 for an elective surgery and you do have an active MRSA
screening protocol at your facility. And so you screen everyone, do a
little nares swab on admission. And they are MRSA positive patient. On the same day, the patient undergoes
a total abdominal hysterectomy. The postop course is unremarkable,
and the patient is discharged on 3/15. On 3/18, the patient’s readmitted
with complaints of acute incisional pain since the day before. The surgeon opens the wound and
notices the fascia is not intact. Now that thing that I’m saying,
you’re saying oh, they don’t do that. They — surgeons very often will really
note what’s going on with the fascia. That’s a big thing for them, has this gone deep
enough that it’s into the fascia layer or not. When they say it’s intact, they’re telling
you it didn’t cause anything there. It looks good. So that’s the key when you say its intact,
that’s a key that you’re probably dealing with something that’s gone to the level of
the fascia, but it’s intact and not affected. Once you get into the fascia muscle, then
you’ve got the deep infection going on. And they send a specimen from the deep wound and on 3/20 the culture results
are positive for MRSA. Is this an SSI, yes it meets criteria — or no that patient was colonized
with MRSA, so this is a POA? Yeah, so surgeons might want to pull
that one, but it doesn’t fool us right? I figured you guys were too smart for that. All right. Still I see the votes coming
in, but let’s go ahead. Yeah. You guys, you nailed that one [laughter]. All right. We’ve all heard it though, right? Yeah, so you know, that’s why it hits home. What infection should be reported? Look back on that case, is this a
SIP, a superficial incisional primary, superficial incisional secondary — man these
are tongue twisters, deep incisional primary, deep incisional secondary, or is this maybe
an organ space SSI, intra-abdominal infection? So go ahead and start your clickers. All right I’ll give you about 10 more seconds. I think everyone’s voting quickly on this. Exactly. It’s a deep incisional primary. The fascia was involved. They were in the deep area when
they got the cultural result. And here you are. Which one did you hit? You hit that one we talked about. They opened the incision,
they deliberately opened it. It was culture positive, and she had increased, acute localized pain from
the day before, all right? And very good. All right. Different scenario. Let’s take this and change it up a little bit. It’s still the same patient. She still came in for that elective
surgery, still MRSA positive. Has the hyst on the same day. The postop course, she’s
still discharged on the 15th. She comes in on the 18th with complaints
again of that acute incisional pain. The surgeon opens the wound,
clear serous drainage is found and notes the fascia is not intact. Sends a specimen from the deep wound. And on 3/20, the culture results
come back as final and no growth. What infection should reported? Superficial incisional primary,
a deep incisional primary, an organ space, or nothing, it’s not an SSI? Go ahead and pass your clicker to someone
who hasn’t gotten a chance to vote, or vote. Give you 10 more seconds. All righty, let’s see if you got this one. Very good that’s correct. Nothing, it’s not an SSI. And I’m going to show you why. Here we go. They did deliberately open this. She had some pain. What came out was a lot of serous fluid. Maybe think of what sometimes
causes serous fluid, seromas. And it was culture negative. They cultured it, but it didn’t grow anything. So this is probably someone who had a
non-infected seroma that they drained, okay? So those are often found in that area. Okay? Make sense? All right, now we’ll get into organ space. Again, now what we did is we removed MD
diagnosis has been removed from organ space. And what I want to try to map out for you on
my hands here is so you have your SSI chapter, you’ve got your superficial, your deep,
and now we’re moving onto your organ space. And then you have — that
has to pair with organ space, your Chapter 17 definitions
of site-specific infections. You have to meet the one to
start looking at the other, okay? And because we removed — I
just want to clarify this, diagnosis from this, it’s
thrown some people off. And I’m going to give you an exact example,
is that you have to meet one of these. Okay? Purulent drainage from a drain
that’s placed into the organ space, okay. Organisms isolated from an aseptically
obtained culture of tissue or fluid in the organ space area, or an abscess of —
and this is this huge general statement here. Or other evidence of infection that’s detected
on direct exam, or during an invasive procedure, or by histopath, or imaging test. This other evidence of infection
is a real catchall. I have had concerns expressed to me of
oh my goodness, we will never be call — or call another post C-section endometritis
because you removed physician diagnosis. And I said no, no, no. And we’re rephrasing this in 15. It’s going to be a much better phrase,
we’re going to say, “No other evidence of infection on gross an anatomical exam.” Okay? So what happens when you have a patient
who comes in, they’ve had a C-section, they come in febrile, tender, the
physician is usually palpating the fundus and it’s very, very tender. The physician at that point it like oh my
gosh, I think we’ve got an endometritis. That is that other evidence of infection. And then you then go and see if that patient
actually meets your endometritis definition. So that’s — I want to kind of explain that that
C is a huge category, that is basically saying, this has started a surgeon on the path of
looking at what is going on with this patient and now — when you don’t have like
frank purulence, or a drain put in, or an abscess that’s obviously seen on CT,
you know, that lets you go down the path to see if it ultimately will meet. We do have — so the specific sites of infection
that you can use after SSIs are listed here. And we do have a new definition added. It didn’t replace one. We still have joint infection down here. I’ll get this little, please —
where’d my mouse wake up again — ah. Well, it moved over here. I’m like that’s where it went. Okay. Joint infections still exist, but it isn’t if a person has a prosthetic
joint in place, okay. If they’ve done H-pro or a K-pro. And you have — you’ve had
an H-pro, K-pro procedure. For H-pros and K-pros you use this new
PJI definition and if you are a place that follows everything and you just had sort
of like a wrist surgery that got infected, or an ankle or something like
that, joint still exists for that. But you won’t actually — under H-pro and
K-pro, when you look at your dropdown now, you won’t find joint listed
anymore, you’ll just find PJI. Okay? We’re going to cover that briefly. We can’t do it in detail, but. Because a lot of you all are
following hips and knees, I want to, you know, give some time to this. So number one, I will tell you right up front, you will be calling less
PJIs then you call joints. Your numbers are going to go down. It’s the kind of thing to note in your
infection control committee minutes. I don’t know if you keep little magic arrows
of timeline of this is when something changed. Because think about our old PJI definition. You could have a single coag negative
staph that grows in broth from an aspirate of actual joint fluid, and
that met our joint infection. Okay? And this new definition was done after
much, much, much work and a huge conference of the MSIS, which is the
Musculoskeletal Infection Society. And then we worked in collaboration with them. That’s new harmony we’re talking
about, to really get a definition that I think our orthopedic surgeons are
really going to respect, but I think — and hopefully you all are all going to your OR committee meetings when
they happen once a month. This is something you need to take to your OR
committee meetings and you need to educate them that we have a new definition
for our joint infections. It’s based on your societies,
you know, the Orthopedic Surgeon, the Musculoskeletal Infection
Society’s definition. This is almost identical
to their new definition. So it should make your orthopedic
surgeons very happy. But they need to be informed,
because if they have a little less than maybe — I want to say this correctly. If they’re possibly not following best
practice for what you should do to rule out that you have a true joint infection, them
knowing what’s in here may change that practice. And a big one be the fact that you’re
going to need two positive periprosthetic, that’s your tissue or fluid down at the level
of the joint, cultures with identical organisms. Not the antibiograms don’t have to match,
just you’re going to have Staph aureus in two cultures, or you’re going
to have Staph epidermidis in two. They have to be matching and identical. And before a single culture
could buy you a joint infection. The other and any of us who’ve worked a lot with
hips and knees, know that sinus tract and in — I don’t — the slide would have been insane. But there is a definition of what a
sinus track is in the new PJI definition. But what it comes out as the patient presents
it looks like they have a little defect in the incision and pus is like coming
out and then when they take them back, they actually find that this is this
tract of pus is coming like right from the knee joint and exiting
out of the incision. That’s called a sinus tract. So if they just see that sinus tract and they
didn’t even get any cultures, and they take them to the OR and they’re like
you see that keyword — oh my gosh, they have a sinus tract,
that will meet PJI definition. Or, so here’s where you get
where there’s less evidence. Here’s where you have a single
tissue or fluid here. If you have a single, you’re going to
need some other blood work to be done. And on the form you’re just going
to click off when you enter it. Other positive lab tests. Because these all fit that criteria. You’re going to need to see an elevated
C-reactive protein, or an elevated ESR. Both of these are indications
of inflammation in the joint. So that’s a key one. And there is — this is my last correction. It was a typo, it was not there originally, but
sometimes our manuals do a little magic thing. This was a C-reactive protein
which came over as 100. That would be like saying a
patient has a fever of 370 degrees. You will never see a C-reactive
protein of — it was 10 is what it is. So it’s corrected here. It is not corrected in the manual yet. So it should be 10 not 100 there. Then, you’re going to also have WBCs, C-elevated
— WBCs in your synovial fluid would be B — or this is a new practice they’re doing more. There literally doing like
what we kind of do on urine. They’re doing a leukocyte esterase test strip. And if it’s a leukocyte esterase positive,
if you have a practice that’s doing that, that will also meet B. And then
the last one is you have greater than 90% PMNs showing in the fluid. So you’re looking for infected fluid and
a single positive, but any of these — three of these five will also
buy you a PJI definition. Okay? If a patient has an infection in the
organ space that was being operated on, I think we’ve covered this
enough, and subsequent continuation of this infection type during the
remainder of the surveillance period, it is considered an organ space SSI, if the
organ space SSIs site-specific criteria are met. Again, you can have a patient — it’s not
like you open somebody up and say, “Oh, they ruptured their colon,
let’s just leave it open.” They do everything, everything in
their power to clean out that patient. They do colectomies. They might form a colostomy. They throw antibiotic washings
numerous, numerous times. And they give them usually extended antibiotics. They are doing everything they can to prevent
that patient, but we know those patients that are wound class three and four are at very
high-risk of getting SSIs and that is calculated in your SIRs in the data that’s sent over to us. And it’s even going to be doubly calculated — we’ll be able to see what’s happening
with those that were left open? How often are they getting infected? Or did it work, all the washouts that they
did and everything they did to prevent it. So here’s an example, on 8/1 a patient presents
to the ED with an acute abdomen and is admitted to the OR on the same day for a colo-resection. They found peritoneal abscess was
noted at the time of the surgery. The abscesses were drained
and thorough abdominal washout of the incision was loosely closed
with some packing between the staples. And the JP was place in an adjacent stab wound. The patient was discharged, wounds
were healing well on the fourth. On the eighth they came back to
the ED with fever, abdominal pain, and purulent drainage via the
JP drain that was still in. This is reported as an SSI IAB, because
it meets criterion three A. And I’m sad to say I have them all memorized. That’s the one where you basically
have a drain that was placed in the OR, is draining purulent drainage,
we’re talking about coming from the outside, not a localized infection. And they came in they were symptomatic. That’s criterion three A of GI IAB. And I believe — I think
Courtney can correct me here. You all were given in your
resource manual the IAB definition from Chapter 17, I think you have that. If you want to look at that. It’s like everybody’s favorite
definition now that we do colos. All right? So let’s — in Chapter nine again, this
is repetitive, I have to take this out. We have a lot of organ space
reporting instructions as well. And these are just some of
them that we’re going over. So please, you know, read over, after the organ
space we have reporting instructions specific to them. So when a patient has an SSI
and has more than one operation. So if a patient had several NHSN operations
prior to an SSI, report the operation that was performed most closely
in time to the infection date. And this does not apply to
that, though, 24-hour rule. I’m not talking about two done within
24 hours, because then you only have that first denominator in your data. So here’s an example, if you have a patient
who underwent a colo on 2/14, one week later, when they’re still in the
hospital, they go back to the OR and they have an appe, via the same incision. They develop an incisional SSI on 2/28. This SSI is attributed to the
second procedure not the colo. Even if you’re not following that in
your plan, you don’t want to jump back to the colo procedure, they’ve had a
major other NHSN operative procedure, so you attribute to the most recent. Let’s do case nine. So, on 3/10 your patient is admitted and
underwent a hemi-colectomy due to colon cancer. The wound class was listed
as clean-contaminated. Four days later, their temp is
38.7, they have abdominal pain, ultrasonography shows an
intra-abdominal abscess. They take them back to the OR
for an I and D of the abscess. The specimen collected for
culture, and antibiotics were begun. The abscess grew, you know, E. coli. They were discharged home on
oral antibiotics on the 18th. Does this patient meet criteria
for an organ space SSI? Go ahead and use your clickers for this. It’s a voting one. Give you 10 seconds. Almost everyone has voted, I can
see from my magic window here. Yep. Very good. Yes. And here’s the reason. You’ve got occurred within
the proper time period. Abscess was within the intra-abdominal
organ space. There was actually an aseptically
obtained specimen as well at that time. And they saw — there was an abscess seen
during, they took them back to the OR. So this can meet on more than one level. So this is — and meets the
definition for an organ space. And it has to then meet the IAB criteria. So, okay? So two different criteria
must be met for an organ space. Your site-specific organ space,
where they saw the abscess on CT and then took them back and found it. And those of the site-specific. And all those site-specific organisms
are in Chapter 17, the HAI chapter. What type of SSI does this patient have? Is it a superficial primary, a deep incisional
primary, an SSI organ space intra-abdominal, my GI IAB as this is called, or SSI —
there’s another one which is called GI GIT, which is gastrointestinal; one’s intra-abdominal
and one’s — the GIT is our gastrointestinal? Which one do you think this
patient met based on the findings? Okay, 10 more seconds. Almost all the votes are in. Very good. I was afraid, now there’s a — that maybe that
would trick you up a little more than it did. Not that I’m trying to trick you. But this is a GI IAB intra-abdominal
which means — and this is — at the top of each of these
definitions in Chapter 17, it tells you where to apply this definition. So a GI IAB infection means it’s not
specified elsewhere under gallbladder — it’s an infection that’s
not specified elsewhere. Such as, these are our gallbladder,
your bile ducts, liver, excluding a viral hepatitis,
your spleen, your pancreas. All these infections are
the intro-abdominal space. Your peritoneum, subphrenic,
subdiaphrenic space, or other intra-abdominal
tissue not specified elsewhere. So the intra-abdominal infection has
to meet one of the following criteria. The patient has to have an
organism or an abscess. Now we did add this last year
this said organisms cultured from purulent material from
the intra-abdominal space. But a lot of times they wouldn’t say — use the word purulent, even though they were
saying it was an abscess they were culturing. So we added — we did very
little changes to Chapter 17, but we felt this was importance enough
with how heavily this criteria is used to make sure we know that if they
go in, they’ve seen an abscess and they’re culturing the abscess and there’s
organisms found, that will meet criterion one. And then the next one is they have
abscess or just other evidence of intra-abdominal infection
during an invasive procedure. So they can go in and see a really bad
abscess or really inflamed peritoneal cavity. And they cannot culture. Because I have this question’s
in my mailbox right now. Can you have an SSI and not
have a positive culture? And hopefully by you seeing this,
you absolutely can meet SSI criteria where a culture is not sent. And the last one is the one that they have to
have two of the following signs and symptoms; fever, nausea, vomiting,
abdominal pain, or jaundice. And one of the following, and these are
— I’m not going to labor over these. You all know these. We didn’t change these definitions at all
and we’ll be touching on a couple of these in some cases coming up all right? So what you think about is the really most
specific ones are up top and when you get into maybe a little less certainty. Is this really going to meet GI IAB? We want to see some symptoms in here
as well as this, you know, so these, as you see there’s no symptoms
associated the patient has to have. This asterisk here means with
no other recognized cause. So that is very much of a clinical thing
you have to look at based on the case. Now, why was this not a GI GIT? The person had a colo procedure, we operated
on their colon, so why wasn’t this a GI GIT, well because this was not an infection. The GIT tract if you look at
it, it’s really for things like the stomach, the actual colon itself. Things that are a part of the actual tract. They did surgery on that, but
it actually expanded and went in to cause an infection in
the intra-abdominal area. So therefore, the IAB was the
appropriate choice for this kind of general intra-abdominal infection. Let’s change the scenario one more time
and let’s say at the time of the I and D, it was discovered when they took him back in that the patient had suffered
an anastomotic leak from which all these abscesses had developed. Does this change your determination
of this being an SSI IAB? No. This was not a voting. Although an anastomotic leak can be
— is a complication of the surgery, the fact remains that this patient
meets the criterion for an SSI. If the surgery hadn’t been performed, there’d
be no anastomoses that could have leaked. It’s the complication that caused an infection. That being said, does every single
anastomotic leak cause an infection? No. You can get that patient there super early. It can be a tiny leak, but they’re still
becoming symptomatic and they get them to the OR and they’re just — they
don’t meet that criteria. They still have to meet the criteria. They often will, but it isn’t an automatic
that you say, oh anastomotic leak equals SSI. All right let’s try this one, case 10. We have a patient has an
abdominal hysterectomy on the 22nd. They come in on the first with
pelvic pain and a temp of 38.4. And an MRI is done and reveals there’s some sort
of fluid collection in the deep pelvic tissue. The surgeon opens the patient — goes
back to surgery, they open the wound in the OR, and drain purulent fluid. Specimen is sent to the lab
for culture and it’s noted that by what the lab says
as an infected hematoma. So maybe that fluid when they got in
there was that dark chocolaty brown, antibiotics were begun and the
incision was closed back up again. And that culture was positive
for Pseudomonas aeruginosa. So what should be reported? Should we report an intra-abdominal
organ space infection, and other reproductive organ space infection,
or an other organ space endometritis infection? What do you think? This is a voting question, go
ahead and use your clickers. A lot of discussion on this one, that’s good. All right 10 seconds, you’ve almost all voted. Okay. Now, I knew this was going
to cause a problem because — not a problem, it’s a teaching opportunity. Because I think that I, when I was in IP, true
confession, I think I was calling these this. And I was calling them IABs. Here’s the reason, and this is again getting
back to where I read you the IAB definition and especially with hyst being reportable. IAB or other intra-abdominal tissue
or area not specified elsewhere. That’s the IAB. Now let’s go to the OREP. Here’s our OREP. I’ve got it cut and pasted in front of you. An OREP is other reproductive. What was done for this patient? She had a hysterectomy, and where
did they find that fluid collection? Deep pelvic tissues. So when you find those deep
pelvic infections showing up, hopefully not very often,
after your hysterectomies. Go look at your OREP definitions. That’s where they should be attributed to. It doesn’t mean every hyst
produces a deep pelvic, it can have caused a general intra-abdominal
if it progressed, but if that’s what this is, and I see a lot, you need to go here. And honestly when you look at the
OREP definition, it is much — it’s easier to hit than and IAB honestly. It’s just when you look at it,
you’re going to hit this more easily. And you may have been missing some of your true,
other reproductive after hysterectomy cases, if you haven’t been remembering this
deep pelvic tissue falls under that. Let’s do case 11. You have a 5/15, 45-year-old female
undergoes an abdominal hysterectomy and a colectomy is performed
through the same incision. And both of these procedures are in
your monthly reporting plan in May. Which one should you enter
into NHSN since they did both? You got it both are entered. And we’ve covered this so much. I’m just telling you. I’m really trying to help you really become
best friends with reporting instructions. So this is reporting instruction number three. I just cut and pasted it from the
denominator reporting instructions. Now, let’s continue this case. This 45-year-old female, who she underwent
the abdominal hysterectomy and the colectomy. It was performed through the same incision. And on 5/19 she spikes a temp to
38, has abdominal pain, and emesis. Ultrasound shows fluid collection
in the abdominal cavity. Fluid specimen for culture is obtained
by needle aspiration and on 5/20 that culture grows E. faecium
many neutrophils are seen, okay? Is this an HAI? Yes. Is this a deep incisional
primary, a deep incisional secondary, an SSI organ space site-specific IAB, this
is an IAB, but there is no SSI infection? Okay, 10 seconds. Very good. This one was not, you know, you got it. And which procedure is this SSI
attributed to, hyst, colo or both of these? Do you have to attribute one to each? Get your voting. All right five seconds, because I
can see almost everyone’s voted. You guys are so quick on the draw here. And you’re right, it’s attributed to the colo. And what’s our rationale? Remember table five here. Okay, we’re going to go on to table
five, where you had two procedures, just a general intra-abdominal infection,
you cannot tell which one to attribute it to and again, this is from our
reporting instructions here. You need to go to table five and look where
the colo is, and look where the hyst is. Okay? So it needs to be attributed
to the colo procedure. Much higher risk in terms of what
may have caused an infection. All right case 12, I think we’re getting
close to the end of our cases here. So this is — on the 15th of January
a 60-year-old female was admitted with an acute abdomen. Sent to the OR and the finding was a ruptured
diverticulum with fecal contamination of the abdominal cavity,
wound class contaminated. Colectomy is performed with
a colostomy formation. The incision is loosely closed with staples to
allow for drainage and antibiotics are ordered. So on 1/19 the patient is progressing well
and is afebrile and is discharged home. She did pretty well, she got out in four
days, they must be a stellar facility. That’s usually a pretty complicated recovery. But anyways she did. She comes back though, it’s now 10
days postop and she presents to the ED with fever, 38.5, abdominal pain. The CT scan is suspicious for some possible
small abscesses in the intra-abdominal space. The MD starts some antibiotics,
the patient is discharged. No cultures were obtained. And the discharge notes states patient
returned with possible intra-abdominal abscess. We also see a lot of these
little squishy kind of notes. So — oops, I went the wrong direction. Okay, so should this patient’s
chart be reviewed to see if they meet criteria for an organ space SSI? Yes. You’re hopefully you found this
somehow that this patient came to an ED. Hopefully you’re reviewing ED notes. Your SSI surveillance should not just
be driven by a positive culture result. I hope after hearing this, you’re
getting that you have to do more. That’s not going to be enough because
for every single one of these criteria, you do not have to have a positive culture
result and you can still meet your SSI criteria. So you will be found when the
validating starts to be underreporting. And some of you are already being validated
— I shouldn’t say starts, if you get picked. Be underreporting — if you
don’t have methods beyond — hopefully you have methods beyond looking
at just your lab’s positive wound results. So yes you all agree. You voted yes, 100% of you. We need to have found this
chart hopefully somehow. Now, does this — yes — okay, this is the
rationale why you want to look at that chart. In organ space, it doesn’t say you
have to have absolutely found it. There’s enough suspicion with saying
this person might have an abscess that it warrants you looking beyond just
the general organ space definition to see, does this patient meet criteria for an inter-abdominal infection
based on Chapter 17 HAI criteria. So let’s go progress here. Does this patient meet site-specific criteria,
a specific type of infection to be reported? And start looking at the case and see
if you think this will meet criteria. I’ll give you about 10 more seconds. This one’s a little trickier I will say. All right, I’m going to close the voting. And the answer is no. And we’re going to go through
why it’s no, you ready? And here’s how you should be doing this. Get your criterion in front of you okay. All right settle down, I’m going
to go through it you ready? Simmer down. Here we go. Does this patient meet criterion
one of an IAB infection? No. Read that. Does this patient meet criterion two;
seen during an invasive procedure? No. All they did was an imaging test
that said possible small abscesses. Let’s look at number three. Did this patient have fever and abdominal pain? Yes, I highlighted those. Did they culture anything on this patient? No. So you don’t meet one. Did they culture two? No. So what are you stuck with looking at now? Three. Three means you have an organism in
the blood and you have imaging test evidence. This patient would not meet criteria, unless
that patient would had had an organism in the blood that would have pointed to it. And this is where people, if they’re not
applying the definitions, just say, “Oh, they think it’s a possible
abscess let’s call it an IAB. It’s so little. I mean there were some possible
small abscesses.” They didn’t drill deep enough to
know if this actually meets criteria. So you also don’t want to be
over calling your infections. If all you have is an imaging
test, you’ve got to remember this for IABs and there’s nothing more. And they don’t do an invasive procedure, and
they do nothing but a positive imaging test. It’s not going to meet. And I want to allow enough time for questions. So I am going to skip case 13. It’s there. It’s nothing that exciting. Because I want. That was the last case, but I
want to get into the last section so I can leave a few minutes
at the end for questions. And I’ll be able to hang out after
Maggie’s section if you need to find me. I don’t want to answer questions
because mine leads right into Maggie’s and you don’t want miss that. So I will answer before Maggie’s
and then I’ll hang around after Maggie’s I’ll come back up front. So this is just completing the event form. You’ve done this. This is my — hang in there
guys, we’re almost done. And this is what you’re going
to complete for every SSI. This is your patient information. Nothing fancy here, but there’s
a new thing I want to point out. Did you notice on the form, Medicare number,
required as of July first of 2014, for events — that’s the keyword; events that are
reported to NHSN for acute care facilities that are participating in the CMS IQR program. This is a new CMS rule. We’ve been telling you about it, but
it didn’t go into effect in January. Now what this is going to mean is —
because I’ve been getting this question. They really wrote the rule that
it’s for events, and not just SSIs. These are your events you’re reporting. You’re doing colos, your hysts. But they didn’t write for procedures. So all those denominators you’re
sending over, because people are saying, “Do I have to have this Medicare
number on all my denominators?” No. Its events. So at this point, until they change the rule, CMS just wants it on your SSI well,
I mean for what I’m telling you. But this applies to all the people who have
been speaking today when you’re reporting for CMS an event, like a [inaudible]. You’re going to need to start
having this number July first. And this gives you the details about it. I’m really good at jumping
the gun on my slides aren’t I? So this is just telling you what I just said. Then you’re going to note if it’s
an outpatient procedure or not. And again, we have that same MDR
infection surveillance question. If you’re not following MDR like staph, MRSA
and the MDRs surveillance plan and you kind of forget and you think, well yeah this
is an MRSA SSI, I think I’ll check yes. You’ll get an error message, that’s
why it’s smart and it will say, sorry you are not following
this plan in your facility. So you can’t kind of mess it up
because the application knows that. And then this is just your basic, put in
your procedure, put in the type it is. The date of the event and the
date admitted to the facility. These highlighted fields are required. You ICD-9 CM does is optional. You do not have to put that in. Was the patient’s date of admission
and date of discharge the same day? If it is that’s going to be a yes there and
then this is are you following this plan? Now this one I want to talk about,
because you all get error messages and then you get a little confused. If you have a patient, you enter the date
the patient was admitted to the hospital when the operation was performed, not
the date when they were re-admitted. So when you’re looking at a patient
who had a procedure on the first, gets discharged on the seventh comes back
in on the 14th with an SSI, if you forget and put down their admission date as the
14th you get a big, fat error message, because you can’t have their
admission precede the actual procedure. So you just look back at the — where
they were and put the admission date for when they actually did
the operative procedure and that error message will magically go away. Location field has always been optional. It isn’t really work or that necessary. These are procedure-based,
they’re not location-based. There’s no transfer rules all that. So it’s just an optional field. So this is, again, reminding you because we
use the admission date of the primary procedure that you’re attributing to,
not your re-admission date. Because your date of admitted has to be less
than or equal to the date of the procedure, which has to be less than or
equal to the date of the event. Then, you have to fill in your specific events. This is where you say am I saying a
superficial, deep, organ space infection, you’re going to fill in which kind. You are going to need to put in which — if it’s
an organ space, you need to select which one. And the thing that’s good if
you haven’t played in this, is that basically we have
figured that out for you. You don’t have a choice of
everything in Chapter 17. If it was a cardiac procedure, you
only have a few choices; superficial, deep, endocarditis, mediastinitis. The organ spaces are filtered
in the dropdown to be specific to the kind of procedure that’s being done. So look at that and know what your choices are. I have a little cheat sheet that next to
colo in my manual which lives by my desk so I have looked through all these
when I somehow had a minute and wrote down what is every organ
spaces allowable for colo? What is allowable as an organ space for a hyst? So that I can remember what’s
on those dropdown menus. It’s really faster than me
thinking, wait can I call it a this? I just have it written down. Then you’re going to say your site-specific. How does this meet? Why do you think this met the criteria? And you’re going to fill that all in there. And this is a required box. You have to say how you found the procedure. Was it when the people was still
in-house and had never been there, post discharge surveillance, readmitted to your
facility, or readmitted to a facility other than where the operation was performed. And again, this is where we have to rely on IPs
to give us that information that we had someone that you did a HIP on and now
they’re back here with an infection. Again, this is required, did the
patient have a secondary BSI? Yes, no? That’s required. Did the patient die? Yes, no is required. Now again, I’m kind of the first one
who’s really going through actual entry of the form and I want to address this. This is a required field, back in the old days,
when it was NIS and I’ve been there since then. Been there done that. There used to be a yes, no, or unknown. But they got rid of that. So it’s yes no. And basically, what we like to say. If you see in that death note
summary that the patient died from a surgical site infection, you can say yes. But with litigation and risk and
everything else, I that’s all we’re asking. Did the physician who wrote the death
summary for a patient who expired say it was because of a surgical site infection? I think if they say that,
comfortably you can say yes. If you can’t find that that’s documented
in the chart, I would select no. And then lastly, you’d have your discharge
date is still an optional field here. If they identified a pathogen. And do you necessarily have a pathogen
when you have an SSI, no not necessarily. You’re then going to go in the back
and you’re going to have your dropdown of what infections — pathogens were found. Now I want to point out something here
because if you haven’t discovered this, when you’re actually in your application,
now I don’t know how many of you are actually in the application and entering
these themselves. Some big facilities, the IPs actually filling
something out that then goes to someone else who might be more of an administrative
assistance level, who’s really dealing with the application. But if you’re not and you’re doing
this yourself, what throw people off, when you’re in the application and you’re going
to enter your organisms, the organism list. You can imagine, you know
how many organisms we have. It opens up with the most frequently
hit organisms that we think people use. So what will happen is I’ll get emails that
will say, this person has enterococcus species or Enterobacteriaceae species and
I can’t find it in the dropdown, I guess it means I don’t have to put this in. No. When you enter that organism
list, go to the very bottom and there’s a thing that says all pathogens. Select all pathogens and you
really see the complete list, but we don’t want to make you
fight through every single one. So you’ll find your less frequent
odd ball organisms on that list. See, I’m going to be giving you so much,
I think my mailbox is going to be empty from now on, what do you think [laughter]? Yeah, yeah, no more emails? All right. Now again, and you’ve heard this in every
single one, so I’m not going to belabor it. You need to pay attention to your
alert page when you open it up. And you may be an alert that says look you’re
missing one procedure associated event here. It’s like, what does that mean? So what you’re going to do is go to your events
and it’s going to show that it’s incomplete and it tells you that that — you
did a hysterectomy on a patient. You have some hysterectomies you’ve entered. But there’s been no SSIs attributable. And that’s great. You did a couple, but nobody had SSI. You just need to say that
we had no SSIs attributable to this procedure that’s in our reporting plan. They just want to make sure
you didn’t forget to enter any. Especially, when states and
people are being validated. They really want to know that it wasn’t just —
oops, I forgot to put them in, it’s really no. I didn’t have any. And then you’re going to report the
no events and click the save button. So in summary you want to complete and
enter a surgical site infection record for every procedure that’s
in your surveillance plan, using all these wonderful instructions
that I’ve been pointing you to. Now here is the — so it’s in one spot. Here’s the errata I told you about. The three things; non-primary closure and
the key terms, and table of instructions. Please go reprint it, it’s
correct what’s in there now. So just — I want you to
have the correct definition. The not incidental to another procedure should
be crossed out from table one, next to appe. And that PJI definition, your
C-reactive protein should be greater than 10, not greater than 100, so. All right. Now, I want to give you a very quick heads up. And we’ll probably have more details
by the time APIC comes around. But what’s coming in 2015. So the big thing here. And probably a lot of you
have gotten this email. It’s all — this is all I know right now. And maybe Dawn knows more, but this
is the information I have right now about our transition to ICD-10,
CMPCS and CPT code based procedures. So CDC is actively working,
we’ve received some of these now. It’s a huge project. We had to bring on people that
were specialty coders to do this. We are mapping all of the ICD-10
CMPCS codes and the CPT codes. We’re offering dual mapping to all
of our procedures that are followed under SSI surveillance and we are anticipating
that these will be available by July of 2014, so you’ll be able to kind of get
a look at what they are and share with IT and do whatever you need. The ICD-10 CMPCS codes will replace
ICD-9 CM codes on October first. Unless something changes. We’re still only hearing these
go away on October first of 2014. But NHSN will not have the ability to
receive these codes in our application. Think about these application bills,
until the January 15th release. So we can’t take ICD-10 codes until January. So the guidance we’re giving you right now is
that the NHSN guidance for that last quarter of 2014, so it’s your October,
November, December, if ICD-10s role out when
they say they will roll out, is that you’re going to want to not use codes. And maybe many of you don’t. You won’t put in an ICD, you know,
10 code, because we can’t it, but you’ll say this is a hip, this is a
colo and you’ll have the cheat sheet by then that you’ll know what your ICD-10
hips, and colos, and hysts are, but you just can’t put the actual
code in, because we can’t take it. And then at the time of the January release,
we’ll be able to accept the new ICD-10 codes. We don’t want you to go back retrospectively. You don’t go back to that
last quarter and put them in. It just doesn’t exist in our 2014 applications. You just get to move forward in ’15. So you’ll just be putting in procedure
names for the last quarter and no codes. And we’re also going to have CPT codes. And what else is coming in 2015, I want to
leave five minutes for questions or [inaudible]. PATOS. We’ve been talking
about this for a long time. In 2015, a new field’s going in. It’s on your numerator form. I love things on the numerator because
we’re all looking at those charts anyway. It means that this tells us, it captures a
condition or a diagnosis that the patient at the time they went to
surgery, they had an infection. This is telling us that when
that patient went to surgery, the physician documented that
that patient was infected. That would be your ruptured appendixes,
your ruptured colons and all that. And there’ll be a field when
you’re filling out an SSI that you’ll be say yes this was
present at the time of surgery. I think that will be very helpful
and something you can really trust that you’ve looked at it and you’ve noted that. The last one that’s going to come
for H-pro and K-pro procedures and this is going to be denominator data. This has been wanted for a really long time. If a total or partial hip revision
is being done, it’s being associated because of a prior infection at that joint,
you’re going to be able to have a field that says prior infection of this joint, for
those joints that just keep coming in infected and you can’t seem to get it cleared up. The end. And are you at the end of your rope? [ Applause ] All right so if you — the
mics have been turned live. So if you want to come to the mic.>>Yes.>>Hi. This is Lisa from Fairview in Minnesota. So if we have a patient that comes in say in
our colo, they’ve got a rupture or something like that, they come in, they have an abscess and say we do multiple procedures
over multiple days. So the surgeon goes in over
multiple days and is cleaning out, and cleaning out, and cleaning out. Do we have to call that a separate
surgical site infection for every? For every? You see what I’m saying, if they’re having
five operations, is that five different?>>Well, I should have addressed
that and I thought I had it in here. Once you have a procedure done and if they
go back and do like an I and D to that wound, which you wouldn’t be doing five
colos, you’re doing I and Ds, then infections that occur
after that are attributable. You have there — we have in our reporting,
if you do an invasive procedure at the site. Like if you have a patient who had a joint
replaced and developed a big hematoma and they go in and have that hematoma aspirated
and it’s not infected, it’s just they had to get rid of that hematoma, and the infection
occurs after that invasive manipulation, it’s not attributable to the H-pro, you could have easily introduced
something during that procedure. Same, if they had that colo
the clock stops ticking — starts ticking again when they take them back and have another operative
procedure whether it’s just an — you know if they find that
first SSI at the I and D. Yes, that’s yours because it’s the
first infection after the colo. But if they keep having them, they’re
not attributable back to that first colo, because you’ve had other invasive procedures.>>Okay, so would that go
for any surgical procedure, say someone comes in and they have a deep wound. And so maybe that’s not reportable,
but that’s something that we follow. So if they have a deep wound and we keep
debriding that wound or whatever over days?>>That I would want more detail. I’m very, very reluctant to answer
an actual case without the details. So what we said, the opening of a
wound and that is not healing properly, and it’s in the protocol, and it starts —
you have to start doing some wound packing and wound management, that
is not considered invasive. You’ve opened up this superficial incisional
wound and you’re dealing with trying to help it. That’s now what we call an
invasive manipulation. Invasive manipulation is going
down into deep organ spaces, going down into the deep
joint and that sort of thing. Not the management of a wound
— postop wound to help it heal.>>Okay, great thank you.>>Often they meet anyway, when they start
opening them up, you’re going to hit one of those, because they’re opening it
and culturing it, but if they haven’t and they eventually do, you
will need to attribute that if it’s in the surveillance period. Yes?>>I have a question on that same slide
that you made the change for PJI definition in the HAI Chapter has a typo and it’s
greater than 10 not greater than 100. On the one before that in A;
three A. It says elevated serum, C-reactive protein, and you said or electrolyte?>>Right.>>And is it and? It’s printed as and, so is it or or is it and?>>It’s or.>>Thank you. Yeah so, okay we’re going to start
Maggie’s and then she and I can both — we’ll have more time for questions at
the end, but we want to have Mag’s. Thank you. [ Applause ]>>I’m back [laughter]. But you guys won’t have to see me
tomorrow, well at least not up here so. Oh, I don’t feel so sad about that [laughter]. I get to relax tomorrow a little bit. Thank you Courtney. All right. So, I’m really. I just want to spend a few moments talking
about the procedure import process. I’m not going to go into great detail about it. But really, you know, in our past
training courses we had included this type of training in with the protocol training. And we thought, well let’s, you know,
lighten this a little bit and just focus on how the changes have impacted importing data. So, I’ll briefly review that
procedure import process. And we’re going to focus today on CSV files. We know that many folks are using
Clinical Document Architecture, or CDA. But we’re not going to be
focusing on that today. And of course I’ll discuss the 2014 changes. Okay, so on our website, actually it’s
on the SSI reporting protocol page at the bottom we have a section
called Supporting Materials. And in that section we have
specifications, file specifications, and resources for importing
procedure data using a CSV file. We are currently updating a training slides
set that will go into more in depth materials about the process than what I’m
going to be going through today. So those will be up on the website soon. In the room, can I get a show of hands,
how many people import using CSV? Wow, quite a bit of people. That’s great. Okay. So hopefully you’re aware
of some of these changes already. But, if not then that’s why we’re here. So this is a snapshot of the file
specifications for the CSV import. We do update these as there are
changes to data requirements. So I strongly recommend that if you have
not downloaded this document for 2014 that you go ahead and do so and communicate
this with your IT department or whomever it is that helps you produce this file. So of course you need the help
from your IT staff if you’re going to be importing procedure
level data using a CSV file. So I really just want to drive home
the point that the procedure data that are imported must follow
these specifications. Okay, they have to follow the order
of fields that we have specified here. And you have to actually read through carefully
all the notes that are on that first page. There are a lot of notes. But those notes are there
to help prevent any issues with importing your data while
you’re in the process of that. This is just a snapshot of what the, you know, first section of those file specifications
looks like, with the data fields. And what I want to point out here is these
are in a different order than how they appear on the actual data collection form. So that’s why you have to follow this
order and not the order on the paper form. In addition, we provide specifications
for the values that are allowed, the data format, and the requirements. And these must be followed. So you cannot use your own
format for wound class, or ASA. You have to follow the values that we have here. Because basically, this is
taking the place of data entry. And when you manually enter data, you
don’t just type in the wound class. You actually select from a list of values. So that’s why you must use what we have here. We do have some hospitals
that use custom fields. And you import custom fields
with your procedure data file. But you have to make sure
that those fields are set up in NHSN prior to importing any of these data. So that’s just a heads up. The data requirements that we provide in the specifications document
assume in plan reporting. Just like when you look at the paper
form, and we have all those asterisks next to certain fields, all those
field requirements assume that you are following that procedure in plan. And so the same goes for importing data. However, we do have some fields
labeled as optional for import. And optional for import is a field that is
essentially at the end of the day required to have a complete in plan record. However, these fields were marked as optional
for import, because they were thought of as not being available from OR systems. And so you may have had to use a
different system and it was too difficult to bring it into the import file. So we said, okay you can bring these data in
with these values missing, but at some point, you’ll have to complete it manually
through our data entry screens. And we’ll provide a list in our data
entry screens of your incomplete records. So I really want you all to think of our file
specification as a companion to and not in place of the full requirements for procedures as we’ve
described in our tables of instructions, okay? These do not replace anything. They’re really meant to just
be a companion to that. So in addition to reading through the protocols
for surveillance, the tables of instructions, the requirements on the form, our key terms. If you’re importing data, you
need this in there as well. It’s all one package. Okay? And I am reiterating that point here,
that it is a companion to our protocol. And so all of those requirements
must still be followed. Let’s talk a little bit about
the changes for 2014. I know I mentioned some of these this morning. I know Janet mentioned some of
these, but repetition is good. So wound class for procedures that
have a date of 2014 and forward. You can no longer report these with
a wound class value of U or unknown. For these spinal-level variable
for fusion and re-fusions, again, you can no longer report these with a value
of not specified for 2014 and forward. And the same goes for type of approach,
where you can no longer report not specified. For type of approach we made
a couple other modifications. The value of trans-oral is new for
2014 procedures only and going forward. And lateral transverse is an old
value that is basically retired. So you can only use that value for
procedures dated in 2013 and earlier. Of course, we have our new type
of H-pro and type of K-pro fields. So, previously we just had two variables,
type of hip, type of knee and that was it. Well, now we have additional
fields, looking at specific types of total, hemi, or resurfacing procedures. So once you import a value for your
hip and knee that tells us the type, you will also be required to
complete one of these bottom three; either total, hemi, or resurfacing. These are all separate variables
in your file specification. So if you are importing these
types of procedures, just know that you’ll need
to complete that as well. And we only need values in
one of them, not all three. Course height and weight as we discussed this
morning, or as Janet discussed this morning. This is required for all procedures
dated with 2014 and forward, however, we marked this as optional for import. So this means you can import a
file with these values missing, but you must complete these
manually through NHSN in order for the record to be complete, okay? So just keep that in mind if you have a large
file that you’re importing and you decide to keep these missing, you will have
to complete these at some point. And of course diabetes is required for all
procedures beginning this year as well. Closure technique, again, required only
for procedures dated 2014 and forward. This is also marked as optional for import. So again, you can import these data with
this value missing, but you must complete it at some point manually through NHSN. And the values that we allow are PRI for
primary or OTH for other than primary. In addition, we did change — slightly
change the order of the fields. We had to shift everything
down by one or two variables. So this applies to all procedures,
regardless of the procedure date. So if you’re still needing to import procedures
from 2013, you have to follow this order, and I believe it is just
the addition of a column. If you’re using an Excel type CSV file. So you again may want to
hand those specifications over to whomever’s helping you create this file
and just make sure that everything’s in order. With this, just know that
in our supporting materials on that SSI website, we do have a sample file. And in that sample file we do
include a header row as the first row that includes the variable name, so
that you know what data are supposed to be in each column. Now you cannot import a file with those
variable names in that header row. But if you’re looking to make sure everything’s
in order, you can kind of copy that in to your file, just to make
sure everything’s okay and then you can remove it
before importing your data. So if you’re not familiar, in order to
import a file, once you’ve created your file, you can import data by using
the import/export option in NHSN and selecting the import type
of import procedures, delimited. You’ll be asked to select your
file, which is a CSV file. And then you click submit. And you’ll notice when you submit, you’ll see a
progress bar appearing and depending on the size of the file, it may take a few moments
to get the entire thing into the system. So just be patient. But once the entire file has been submitted, and
actually, you know, now that I’m reading this, I kind of don’t like the word submitted,
because no data are saved at this point yet. It’s really just — I don’t even know what the
right word is, but they’re not yet submitted. So what we’re doing is we’re
trying to just transfer those data into this temporary holding space so that you
can review and make sure everything’s good. You can have up to five tabs
when you import your data. There are inserts, bad data, updates,
multiple records, and duplicate data. Today I’m just going to focus
on inserts and bad data. The other three will be described in the
slide set that will update on our website. So the inserts tab is the good tab. That means everything’s cool. You can import the data as they are
with no additional modification. And what we do is we try to provide you with
the information for all these procedures. But because you can import so many
different data fields, it’s very wide. So you have to scroll your window over if you
want to see some of the additional information. However, if you click edit. It will bring up a very short
screen that’s more vertical with all the data fields
completed for that record. But at that point, if you make any changes and
you click save, it’s still not saved in NHSN. It’s just in this holding place until
you’re ready to finish the import. The bad data tab is just
as it sounds, its bad data. So we are not going to let you import it,
any records that are labelled as bad data. We try to do data quality checks through
this and prevent any potential errors. So if you’re using the wrong value for a certain
data field, or if the procedure date is in, you know, 1909, we’re going to try
and prevent that from happening. But what I wanted to let you know is
that if you see this bad data tab, you cannot import anything. So it is all or nothing. You want to make sure that you are left
with just an inserts tab, or an updates tab. If you have a bad data tab, or anything else,
you’re not going to be able to do any importing. So we recommend that if you have a
lot of records in the bad data tab, stop what you’re doing, go back to
the original file that you have, or go back to the person who’s
going to help you with these data and get it fixed in the source file. Because it could take you a lot
of time to update these records. And again, nothing is saved at this point. So if you leave your desk and you’re
logged out of NHSN, it’s all gone. Okay, so this is just kind of repeating
what I had to say, just on the last slide. So you should only have the
inserts or updates tab. And once everything is good, you click
update at the bottom of that list. And then when all records have been imported, you’ll see a message confirming
that it has been successful. You’ll see that nice little green checkmark
that you often see when entering data in NHSN. So, just a few helpful tips. Facilities will be stopped if the
data are not in correct order, or if they do not leave empty
placeholders for optional fields, okay? So there are a lot of optional fields that we
allow you to bring in, such as custom fields. When you’re looking at the data in Excel,
you have to leave those empty columns for those optional fields, otherwise
everything’s going to be shifted. And hopefully this goes without saying, but — and I know all of you in the room and
those watching on the web streaming, who — this is your job, you know,
you’re IPs, you already know this, but the people who help you may not know this. So it’s extremely important that the same
definitions and protocols are followed, okay? So there are many times where your OR
staff or your IT staff are not aware of our standard CDC definitions
for these data fields. So it requires a lot of teamwork and
communication when you’re first getting started with these files, or if you need
to modify the data in these files for new protocols like we’re seeing this year. Your data managers, your IT staff, OR staff,
they can email NHSN directly with questions if they have any questions
about what something means. They’re free to do that if they’d like. It’s equally important for you, as the IP, to
understand the data elements that are captured from your OR or other systems as well. Making sure that the procedure duration
is in alignment with our definitions. And that other elements are also in alignment. Also make sure your patient IDs are correct. So, you know, we notice that some folks may
have trouble linking SSIs because the data that were imported may be missing
leading zeroes for your patient ID and when your entering the SSI,
you’re including the leading zeroes. So, even though all of these patient IDs here
look very similar to us, to the application, those are completely different patients. Those are different numbers. Any time you add leading zeroes
or dashes, or any sort of prefix, that’s considered a different patient. So, you know, make sure you’re
aware of how the format of those patient IDs are being
used in that import file. And of course, I know this isn’t import talk,
but I have to talk about checking the data. I’m a data girl. So I recommend that data are check to
ensure accurate data have been collected. That the data that you are importing do meet
our protocols and everything matches up. You don’t have to do this
constantly, constantly, but you should do some sporadic checks on this. You should especially check your data if any of
our definitions have changed, or if you’re aware of any changes that occurred in your OR system. Just to make sure everything matches up. And of course, you can utilize our analysis
output options to help accomplish this. Using line lists and frequency tables. We also have a variable called imported
and you can add this to the procedure list or frequency table to look at specifically
those records those were imported to us. Especially if you said, well, you know what? We’re brand new to this, we’re going to try this with one procedure category just this
month to see how everything works out. You can run analysis only
on those imported records. So these are links to our resources
related to importing the data. Again, we will be updating a full slide set that will include much more
detail than I went through today. So, I thank you for your attention. I’m happy to take questions. And Janet is coming up as well for questions. But, before I forget, I was asked to
make an announcement that folks here from Oregon can meet over in this corner
up here at the very beginning of the break which is coming up in about 10 minutes. So, if you’re from Oregon
please meet them over there. And all right, questions? So, I’m going to go ahead and give a shout out
to people that are listening web streaming. Because we have a couple questions
and we haven’t really had those. So I’m going to send a shout
out to Elaine Decker. She’s listening from San
Francisco General Hospital. And here’s her question. She had a little longer of a question, but
I’m going to give you the short answer. She wants to know is there a way that
we know the BMI, we can just enter a BMI and not enter a height and weight. And I’ve been asked this already. And the answer at this point is no. We really want to know that it is a correct BMI and that it has been calculated
using our internal calculator. So we do want to see the height and the weight
and then our application will enter the BMI. So I just wanted to give her that answer. And then I have one other quick questions. This is from Beverly Stergil [assumed spelling]
from Carilion Roanoke Memorial Hospital, are you still on the line, I hope. I don’t know if they can answer. But anyway this was around what I
said about the reporting instruction. That if they are using ICD-9
codes and they have — should any ex-lap be reported
regardless of whether results in a procedure from another category. Now that was the old one. You have to look into it, see
if another procedure was done, another procedure was done,
don’t report the ex-lap. Okay, but we took that rule
away to try to simplify. So if you’re just dealing with line list. So yes if you get a line list
from your OR, from your coders, however you’re getting your line lists. And you have an ex-lap and
a colo, put them both in. Now think of an ex-lap and a colo. If you develop an SSI, it’s
never going to be attributed to the ex-lap because the colo’s deeper. But you’ve got that in your
denominator data, all right? And sometimes they do just do an ex-lap. And those will be in there as well, all right. So I just wanted to clarify that. I’m going to — I think that was
the only thing I needed to clarify. Okay, in the back there? Hi.>>Hi Janet, Joan Hebton [assumed spelling]. I have a comment and then a question. I am a bit concerned about the optional field
for ICD-9 on the surgical procedural form. And the reason relates to some
of the auditing I’ve performed, state auditing that would suggest that there
may be procedures placed in the denominator, for colon, specifically,
that shouldn’t be there. And I wonder when you’re — you
don’t have really any way to know that if you’re only entering
the NHSN procedure code.>>Right. That’s a great question. And I can tell you that I was in a big
meeting room last week dealing with that. It’s that question of when and if we’re going
to go to a process where we are more code-based and we would require that the primary ICD,
at that point it will be 10 code be entered. And we’re not there yet, but we are very
aware of it as an issue and are working at it at a high leadership level right now.>>Yeah, because many times the OR databases that you’re creating your CSV files
do not have that piece of data.>>Right.>>That isn’t tagged on to the
end when it goes to billing.>>Right.>>So it really become a big
concern in light of the trajectory that we’re on about public reporting.>>Absolutely.>>Because I can see SSI reporting
increasing dramatically in the next few years.>>Yeah. I’m a proponent of
— that we are moving that way and I will take your feedback definitely.>>Thank you.>>Back to your group. Yes, on the left?>>Hi, Janet. Thank you. Shannon from San Diego. And I have a question I’ve
been emailing the surgeon and I know we don’t take what surgeon’s say. So I sent him the definition. He did a fusion procedure and
took a patient back and did an I and D of the deep sub-fascia thoracic
postoperative, posterior spinal [inaudible]. And then he found to have an opening in
the inferior part of the thoracic wound that appears to be deep and sub fascia. He cultured multiple layers of that
incision, superficial and deep, however, the deep culture negatives and the
superficial culture is positive for candida. And he claims that since the superficial culture
was positive, then it’s a superficial infection, yet the operative descriptor looks
like it’s a deeper infection.>>Yeah.>>So?>>Yeah. You’ve got it correctly. If it’s meeting the deep, you wouldn’t
base it on just where the findings because of a candida in the superficial area. If that infection progressed into the deep
level, regardless if the culture is negative. You don’t know if it’s the
result of antibiotics. If it’s meeting, you know, there are
culture negatives that will not meet. So you just have to — now that I’ve
showed you those definitions of opening and a culture negative, you know, that.>>Right.>>Make sure you’re not hitting that definition. I would love to talk with you
afterwards, I’m extremely visual, if you could see how I workout
these questions that come to me. It’s very difficult to do and it’s that
case standing without me mapping out date of procedure, date of symptoms,
I like to really see them all. But I can talk with you if you want to
make sure I’ve got the description right, but again I would prefer not to actually answer
like case questions because I need to see those in writing so I make sure
I have all the details.>>Okay, thank you.>>You can grab me afterwards. Yes?>>[Inaudible] from Primary Children’s. I have a question about height
and weight for all procedures. So in our NICU, these babies
can stick around forever. Because it’s a surgical NICU, what
height and weight are we using? Birth weights or at the time of the surgery?>>Yeah, it’s most recent. When you look at the definition, it’s the height and weight most recent to
the operative procedure. So it’s not like, some of our state, their
birth weight is a category they fit into.>>Right.>>But for this when you look at the reporting
instructions and the table of instructions. It’s most recent that you have
to that operative procedure.>>So even if they haven’t weighed in. Well weights we usually get, but maybe we
haven’t measured their length for a long time, we might have a length that’s off. Is it no big deal?>>Well, again, if the baby’s right
there, there isn’t any problem if you realize they haven’t been
measured in a while you can add — especially if they’re there a long
time, you might have four more inches. So but I’m just saying.>>Right, right.>>If the baby’s still there you could
probably stretch that little tape measure out and see what they’re doing now.>>We just don’t get our procedures
until after they’ve been coded. Because it’s all done electronically.>>Oh okay.>>So it’s way out.>>You’ll just have to take
them what it is the most recent. And that’s where you can again have an
education opportunity for folks who know this is for risk adjusted data and say can
we start having in some checklist, pre-op check list that we’ve
got a recent height and weight and it can work very well just
at the bedside, pre-op level.>>Okay, great, thank you.>>Thank you.>>Hi. I’m April with Banner Health. Mine’s an acute question too. We do some surgeries in the
bedside — at the bedside in NICU. And I noticed in your definition you
included operating suites so to speak, and those types of rooms
that meet that criteria. So does that exclude those surgeries
that are done within the NICU because it is not an operating room?>>Yes. That’s a great question. And I’ve had that already a couple times. Because with the little babies, they often — the ones I’m seeing coming
in are cardiac surgeries and they can’t close them right
away due to swelling or whatever and so they have to leave that open. So that is in your denominator
as a CARD with an open. And then they close that incision a week
later, a few days later at the bedside. So what’s happened now, you
have done a procedure, that’s an invasive procedure at the bedside. So the clock stopped ticking. And if after that closure at the bedside occurs,
the baby develops an SSI, it is not attributable to that CARD that was done in a
perfect, beautiful OR setting. Because you did an actually an operative
procedure at a bedside that was not an OR.>>Okay, so we exclude those.>>Yeah.>>Thank you.>>I have a question about a podiatry procedure. Would we follow that for 30 or 90
days if it involves an implant?>>Good question. I am 90% sure, but again, I’m very ICD-9
code based and implant does not matter. Podiatry procedures are all —
oh I can answer that actually. Okay, first of all it’s not
because there’s an implant. Podiatry procedures are not in table one. And if they even are an NHSN
operative procedure — so what you want to go do is look at that
wonderful ICD-9 mapping list I showed you. It’s very likely that they are a big
no and you wouldn’t be calling an SSI. If they happen to actually
be in the other OTH category, all of those are only followed
for 30 days regardless. Remember implant doesn’t come into effect
in terms of our surveillance period anymore. So everything in that 30-day list is 30 days
and you’ll see at the bottom of it OTH, other. They’re all followed for just
30-day surveillance period.>>Okay.>>Okay?>>Hi. I’m Brenda from Western
Maryland Health System. I have a very simple question. Do we have permission to use
your son’s beautiful illustration about the closure [laughter]?>>I will have to tell him that. You know, I don’t see any reason if you have
an ability to snag it go for it, you know. Unless there’s someone can tell me
that I’m telling you something illegal, where’s Courtney, can they grab it? I’ll have to put a shout out to him. I’ll call him tonight and tell him
up there in New York City doing his.>>Thank you.>>Thank you.>>Hi. I’m Joellen. I would just like for you to re-clarify around
the surgical site infections for organ space and C-section that endometriosis can be
possible for part of the diagnosis, correct?>>Oh, absolutely. If you look at that other evidence on exam that
the patient may have an infection that’s going to be things like really fever, and extreme
fundal tenderness and then you’ll go look at your endometritis definition, if
it fits you call that an organ space. Yes?>>Yes, Kathleen Quan [assumed
spelling] from UC Irvine in California. Actually may I ask a question about a
CDA methodology of procedure upload?>>You know, I’ll be honest with you, I can try. But I am not a CDA expert.>>Sure.>>My colleagues, Paul, Malpiedi, and
Mindy Durrance actually–>>No this is a conceptual question.>>Okay.>>Okay [laughter]. So the CDA upload, which is done through usually
a third party vendor does not allow for upload of non-required fields or custom fields.>>Right.>>Which makes it basically useless if we want
to use it for physician specific follow-up.>>So for like surgeon codes?>>Correct.>>Okay.>>Will there ever be a time when
we will be allowed to do that? Because it really diminishes our ability to
use that methodology, which is very helpful in capturing missing data and things like that.>>Right. So excellent question. I know that we’ve been asked this a lot. I believe they are trying
to move forward with that. But I don’t know what the time line is
for actually allowing it on the NHSN side. So I can’t answer it definitively. I just know that from our side we’re trying to
make that work, I just don’t know at what stage. Because there’s only certain points in
time that we can allow updates for CDA. I think it’s just about — well
actually, I don’t even want to say when. I just — I don’t know.>>But the intention is to allow?>>Yes. And so actually what I can
do — I’ll make a note, and you know, for our next newsletter perhaps I can ask
my colleague Paul to make a CDA update in the newsletter just to let everybody
know how we are going in the process.>>That’s be great.>>Is that all right? All right thank you.>>Thank you.


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