Posted 13 Dec 2017
Submitted by M. Rochon
Views expressed are that of the author and do not represent the Cardiac SSI Network.
Surgical Site Infection (SSI) Surveillance: Reducing the burden of data collection to free up time for work to reduce SSI
Those familiar with Professor Tim Briggs’s (2015) Getting It Right the First Time (GIRFT) report will recall his persuasive description of the ‘perfect storm’ facing our healthcare service: that of ever-rising demand colliding against the pressures of financial austerity. One of the recommendations from the report is the GIRFT SSI Audit, to identify and address variation in SSI rates and best practice. At a recent Cardiac SSI Network meeting, many of surveillance nurses were excited to engage with the audit. Even in its first incarnation, the GIRFT SSI audit is well designed: it does not require laborious data collection (only numerators and denominators are required) and it gathers important information on SSI, including the length of stay for SSI, sepsis, return to theatre and mortality.
That said, from a cardiac clinical nurse surveillance perspective, the GIRFT SSI Audit in cardiac surgery will report <10% of SSI burden as compared to those reported to the Public Health England (PHE) modules. GIRFT collects mediastinitis and infection endocarditis; incisional SSI and donor coronary artery bypass graft (CABG) SSI are excluded. This is a source of some frustration for those of us who have worked hard over the years to report and reduce all types of SSI.
Fortunately, there is no need to choose between the GIRFT and PHE surveillance approaches- the two are complementary. The bigger issue facing SSI surveillance is efficiency. In my opinion, the majority of non-SSI data (patient demographics, operative and admission details) is likely to be collected for submission to other external bodies (in the case of cardiothoracic surgery, NICOR). This data should be the starting point for surveillance, requiring only SSI-specific data added to the electronic database.
This improvement is already in hand at some cardiothoracic centres which have ‘bolted-on’ the GIRFT and /or PHE SSI-specific fields to the same database used within their hospital for NICOR submission. This low-cost approach has the benefit of a single internal database used for multiple external submissions (i.e. NICOR as well as PHE, and/or GIRFT submission, as based on selected fields). This multidisciplinary approach (with some locked/read-only features) releases the surveillance nurse time to undertake and/or monitor measures to reduce SSI. Importantly, by reducing duplication and combining datasets of clinical colleagues and surveillance nurses, a separate and potentially expensive electronic surveillance for a single outcome (SSI) database can be avoided. At our centre, the Intellect Dendrite database is used for NICOR and PHE submissions and GIRFT SSI Audit. We have also added fields for wound photo uploads.
Arguably, for superficial wounds, the addition of a digital image is more valuable in determining an SSI than microbiology results. The routine collection images of surgical wounds for Photo at Discharge and WoundCare1 (the latter is for in-hospital wound assessment and documentation) expedites and simultaneously validates the large components of the surveillance programme.
Ultimately, quality SSI surveillance helps to improve patient care and outcomes. Taking steps to bolt-on SSI data may help to achieve this result. In my ideal surveillance world, PHE definitions and classifications would be’ bolted-on’ to the NICOR dataset. This would improve the overall reporting, particularly for denominators (CABG and Cardiac module PHE inclusion/ exclusion categories can flummox even the most engaged clinician!) as well as our understanding of risk factors for SSI (for instance diabetic status for CABG, bypass information for mycobacteria chimaera infections and so on).
If you do wish to streamline your process and reduce duplicate datasets and administration work, the first step is identifying who in your hospital maintains the National Adult Cardiac Surgery Audit data. Meet with them and find out if you can add a few fields at the end of their dataset for PHE submission use. Click here for an example of data headings/requirements:
We may be a long way off from this imagined idyll (or may not agree with the opinions expressed here!), but for nurses working in surveillance it may be worth asking clinical colleagues which database they are using for their data and find out if you can ‘bolt-on’ some SSI fields to make your job easier (and potentially saving money). This can only help in the move towards a single version of the truth to achieve high quality and best value and an integrated performance framework (Carter Report on Operational Productivity in NHS, 2016). If you have the opportunity, get involved with GIRFT SSI Audit with your clinical colleagues and submit your quality improvement project to reduce SSI to the SSI Audit Team – Prof Brigg’s broad ‘call to action’ for clinically-driven change to improve patient experiences and outcomes.
 Surgical registrars will be familiar with which database is used at their hospital. Dendrite Clinical Systems (Intellect or Iweb, older legacy PATS), Philips CVIS (Tomcat), HD Clinical (Datacam), EMIS HICCS or InfoFlex. Only centres with direct upload to NICOR will not be able to take advantage of adding some local fields for SSI surveillance.
Posted: 15 Dec 2017
Submitted by: Lisa Butcher, Lead Nurse for Infection Prevention and Control
Oxford University Hospitals Foundation Trust
Mycobacterium chimaera (M. chimaera) is an environmental non-tuberculous mycobacterium belonging to the Mycobacterium avium complex. M chimaera can cause of infective endocarditis (IE), severe disseminated infection and chronic sternal wound infection in patients who have undergone cardiothoracic surgery. Studies from various countries find that these infections are likely transmitted by the heater-water cooler units as part of the cardiopulmonary bypass equipment.
The risk of infection is low and cardiothoracic centres have already taken control measures as recommended by national and expert advisory bodies. Nevertheless, patients and healthcare workers should remain vigilant as M. chimaera infection can have an insidious and non-specific presentation, is not always identified through conventional microbiology, and requires specific treatment.
As of 7 September 2017, there were 39 cases of M. chimaera infection following surgery on cardiopulmonary bypass, of which 19 were known to have died. The median interval between surgery and diagnosis is 19 months but ranges from less than 1 to 68 months. This delayed onset of M. chimaera SSI or IE places the majority of cases outside of standard surveillance cardiac SSI protocol (which records deep and organ or space SSI up to one year) but all cases with M. chimaera will be reported to Public Health England.
Lisa Butcher (left)
Lead Nurse and Manager for Infection Prevention and Control, Oxford University Hospitals Foundation Trust
Melissa Rochon (right)
QS Lead for Surveillance, Royal Brompton & Harefield NHS Foundation Trust