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Public Health England (PHE)
Recommendations
For
Surgical Site Infection Surveillance
(SSIS)
Sian HarrisVascular Clinical Nurse Specialist in Wound care & Surgical site infection
Imperial College Healthcare NHS Trust
Background
The most common hospital acquired infections (HAI) include:
Urinary tract infection
Pneumonia
Blood stream infections
Clostridium Difficile
Surgical site infection
As a result surgical site infections have been associated with significant morbidity and approximately account to 16% of all hospital acquired infections and predicted to double if patients have: ⁵
A prolonged hospital length of stay
Which has considerable cost implications to the organisation.
Surgical Site Infection Surveillance Service
(SSISS)
Introduction to Surgical Site Infection Surveillance
Participation ⁴
• 429 hospitals in England registered (258 NHS, 171 independent sector)
• 17 categories of surgical procedure
• DH mandated surveillance in orthopaedics from April 2004 (NHS); all
other categories voluntary
• Independent sector must undertake surveillance and publish SSI risk
from 2016 as per CMA order
• Prospective surveillance – data submission by set deadlines
• Hospitals preselect (voluntary) categories according to own priorities
• Hospital data not publicly reported apart from orthopaedics
• Approx. 200 000 records submitted/year
Patient data collected under Regulation 3 (Surveillance and control of public health hazards explicitly including infectious disease) of the Health
Service (Control of Patient Information) Regulations of 2002 under the powers given to Secretary of State in Section 251, NHS Act 2006
What is a Surgical Site Infection?
A surgical site infection is a type of healthcare-associated
infection in which a wound infection occurs after an
invasive (surgical) procedure. ³NG125 guideline 2019
A surgical site infection occurs when micro-
organisms get into the part of the body that has been operated on and multiply in the tissues. ⁵PHE guidelines 2013
A Surgical site infection is an infection that occurs within 30 days after the
operation, and involves the skin and subcutaneous tissue of the incision
and/or the deep
soft tissue of the incision, and/or any part of the
anatomy (for example, organs and spaces) other than the incision that
was opened or manipulatedduring an operation. ⁶WHO guidelines 2018
Surgical site Infection- Superficial/
Deep/Organ/ Space
Occurs within 30 days of surgery (with/ without an Implant)
Involves Skin or subcutaneous tissue
Involves fascial or muscle layers
Involves any body cavity that was opened/ manipulated during surgery
Must meet at least one of the following criteria
1. Purulent discharge from wound incision
Colour
Consistency
2. Culture of organisms and pus cells present:
Fluid/ tissue sample
Wound swab
3. At least 2 symptoms of inflammation:
Pain, tenderness, localised swelling, redness, heat,
Generally unwell or pyrexia
Abscess/ other evidence of infection in deep incision/ Organ/Space
Re-operation/ histopathology/ radiology
4. Clinicians diagnosis of a Surgical site Infection
1.
2.
3.
Surveillance database
Patients personal details
Surgical procedure- American Society Anaesthesiologists Score (ASA), OPCS
codes, wound class, and operation duration
Antimicrobial prophylaxis, multiple surgical procedures and post discharge follow up survey
Public Health England database is split into three main sections. ⁵
Participating Hospitals In the
Surveillance programme
Orthopaedics is a mandatory
requirement from DH to
undertake surveillance and
have four surgical categories to choose from: ⁵
Hip replacement
knee replacement
Repair of neck of femur
Reduction of long bone
fracture
80%
20%
15%
Data provided by Public Health England (2019) Surgical Site Infection Surveillance Service (SSISS).
National benchmarks
0.0 2.0 4.0 6.0 8.0 10.0
Knee replacement
Hip replacement
Breast surgery
Reduction of long bone fracture
Repair of neck of femur
Cardiac surgery (non-CABG)
Spinal surgery
Abdominal hysterectomy
Cranial surgery
Gastric surgery
Cholecystectomy
Vascular surgery
Limb amputation
Coronary artery bypass graft
Small bowel surgery
Bile duct, liver or pancreatic surgery
Large bowel surgery
SSI risk (%)
SSI risk by category of surgery, England, April 2013 – March 2018
2.7% (2.0-3.5)
2.5% (2.1-2.9)
Y-axis is arranged from
highest SSI risk to lowest, with
the hip and knee SSI risk now
being quite low
X-axis shows the SSI risk
%
2017 Q3 2017 Q4 2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Inp
ati
en
t/re
ad
mis
sio
n S
SI ri
sk
foll
ow
ing
va
sc
ula
r s
urg
ery
(%
)
National benchmark Hospital A
Data provided by Public Health England (2019) Surgical Site Infection Surveillance Service (SSISS).
Using surveillance data
Hospitals can draw comparisons to the benchmark and
assess their risk of SSI over time
This trend graph shows an anonymized hospital compared
to the National benchmark for Vascular surgery
The Y-axis is based on in-patient and
re-admission detected SSI
The X-axis shows time displayed on a Quarterly
basis (3 month surveillance periods) from March
2017- February 2019
Risk Factors of SSI
<25 kg/m2
25-29.99 kg/m2
≥30 kg/m2
0.0 1.0 2.0 3.0 4.0 5.0
Inpatient/readmission SSI risk following vascular surgery (%)
Hospitals can better understand their
results by assessing important risk
factors such as patient BMI
Patients with high BMI are at increased risk
of developing SSIs for the following reasons:
usually have poor nutrition
Increase risk of dehiscence
co-morbidities (diabetes, respiratory
problems, reduced mobility etc.)
all of which can cause delay in healing and
infection
Things to consider before the
implementation of PHE SSIS
Follow up Clinics with doctors- Communicating diagnosis of SSI
G.P Surgeries
District nurses
Wound swabs
Geographical area
Resources- staff to be trained in SSIS
Documentation of level of infection/ photos- Superficial, Deep incisional, organ/space SSI
30 day follow up or 1 year follow up for implants
North west London
Catchment Area ³
Central and North West London NHS Foundation Trust
Central London Community Healthcare NHS Trust
Central London (Westminster) CCG
Chelsea and Westminster Hospital NHS Foundation Trust
Ealing CCG
Hammersmith and Fulham CCG
Harrow CCG
Hillingdon
CCG
Hounslow CCG
West London (London Borough of Kensington and Chelsea and Queen’s Park and Paddington) CCG
Brent CCG
Care Information Exchange
Is a portal also known has Patients Know Best and aims to provide the patient
with online access to their own healthcare records
The record can be shared with any other health professional involved in the
patients care or a family/ carer
The record is hosted within the NHS secure network
Care Information
Exchange
36,665 patients
How the Care Information Exchange (CIE)
will be used in vascular
On Discharge- Patients will have a wound care management plan
The dressing product and regime will be shared with community health professionals.
Wound Photographs will be uploaded onto the patients record
Encourage self-care
Patients can monitor their wounds against a traffic light system
How to monitor the Wound
This traffic light system provides a visual
aid to patients,of how to monitor their
wound
It provides clinical signs and
symptoms
Contacts numbers and health
services that they can access
Wound care Plan
Provides an overview of the care plan
Dressing plan and frequency of
dressing change
Contact numbers and email
address
Contact details for the
pharmacy department
Wound pictures so that
wounds can be compared
post discharge
Next Steps For Vascular
SSI SurveillanceTo implement the Clinical information exchange portal:
This is to aid a safe patient discharge
Provide robust follow up for 30 days and 1 year for implants
Reduce hospital length of stay
Reduce cost implications to the Trust
To invite G.P surgeries and District nurses to register on the CIE portal:
Effective communication between primary and secondary care sector
Utilising the same system to see the patients care pathway
Patient engagement:
To empower patients to self care
Reduce any unnecessary anxiety or stress upon discharge
To provide better patient education and awareness- of the signs and symptoms of a SSI and who to contact if they need support
Summary
To collaboratively bench mark against other Vascular services around the country
To maintain database collection for PHE by using the CIE portal
To compare re-admission rates due to SSI with previous years
Network with the primary care sector and work in partnership
To prevent re-admissions to hospital and re-interventions
To reduce cost implications to the organisation
Better quality of life for the patient
References
1.) Data provided by Public Health England (2019) Surgical Site Infection Surveillance Service (SSISS).
2.) National Institute for Health and Care Excellence (2019) Surgical Site Infection: prevention and treatment [NG125]. London: National Institute for Health and Care Excellence. Available from: https://www.nice.org.uk/guidance/ng125/chapter/Context [accessed 10 October 2019].
3.)Imperial College Healthcare NHS Trust (2019) West London Sustainability and transformation partnership (STP). Available at: https://www.england.nhs.uk/integratedcare/stps/view-stps/north-west-london/North [accessed 10 October 2019].
4.) Patient data collected under Regulation 3 (Surveillance and control of public health hazards explicitly including infectious disease) of the Health Service (Control of Patient Information) R5.)Regulations of 2002 under the powers given to Secretary of State in Section 251, NHS Act 2006.
5.)Public Health England (2013) Protocol for surveillance of surgical site infection. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment data/file/633775/surgical_site_infections_protocol_version_6.pdf [accessed 10 October 2019].
6.)World Health Organisation (2018) Protocol for surgical site infection surveillance with a focus on settings with limited resources. Available from: https://www.who.int/infection-prevention/tools/surgical/SSI-surveillance-protocol.pdf [accessed 10 October 2019].
Contact details
Sian Harris – Clinical Nurse Specialist Wound care/ Surgical site infection
Email address: [email protected]
Telephone Number: 02033126666 extension: 25332
Mobile Number: 07913428351