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The Bean Count

For too long, orthopaedic surgery has been the belle of the UK surveillance world. But outside of mandatory surveillance, cardiac surveillance is where it is really happening. Innovation in reducing SSI? Endoscopic vein harvest, minimally invasive approaches, internal fixation systems, external sternal supports, surgical bras, digital pictures of the surgical wound to improve patient information, dedicated cardiac patient groups…cardiac surveillance is spoilt for choice when it comes to patient safety initiatives.

But what I have noticed from hanging around with surveillance colleagues (other than our general agreement that surveillance is one of the best jobs around), despite some amazing innovation and quality improvement, there is still an awful lot of bean counting going on. Some rather high-end bean counting actually, if your hospital participates in both of the national PHE modules (CABG and Cardiac [non-CABG]). Bearing in mind that the examples below each represent only one patient, there are a number of possible outcomes. To wit,

1. A patient with a superficial sternal SSI, primary admission, onset day 12, following CABG + valve, primary closure.

2. A patient with a superficial sternal SSI, primary admission, onset day 12, following CABG + valve, delayed closure.

3. A patient with multiple SSI- one sternal SSI and two leg SSI. This was identified on primary admission, onset day 12, following CABG + valve, primary closure.

4. A patient with multiple SSI - one sternal SSI and bilateral leg SSI from vein harvest. This was identified on primary admission, onset day 12, following CABG + valve, delayed closure.

5. A patient with multiple SSI - one sternal SSI and bilateral leg infections from vein harvest. All three SSI are deep incisional infections, identified on readmission, onset day 40, following CABG + valve, primary closure.

6. A patient with multiple SSI- one sternal SSI and bilateral leg infections from vein harvest. All three SSI are deep incisional, identified on readmission, onset day 40, following CABG + valve, delayed closure.

7. A patient with mulitple SSI - sternal SSI and bilateral leg infections from vein harvest. All three SSI are superficial incisional, identified on readmission, onset day 40, following CABG + valve, delayed closure.

8. A patient with a superficial sternal wound infection. This was identified on primary admission day 12, following aortic root repair, primary closure.

No bean(s).

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Bean Key

Red = SSI for PHE submission,

Blue =CABG case for PHE submission

Yellow =Cardiac case for PHE submission

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I don't have a problem with recording multiple SSI for CABG patients - we want to reduce any /all SSI. But, in my opinion, we are losing some elements of data quality by double counting patients and/or excluding cardiac operations. Why shouldn't the national SSI surveillance data align with national the clinical cardiac dataset? And without wishing to talk myself out of a job, which hospital can afford this kind of duplication of processes?

Also, and without wishing to single myself out someone you should avoid sitting next to at a dinner party, wouldn't it be pretty great if NICOR/SCTS adopted the PHE protocol to remove this inefficiency?

Scenarios

1. Submit to CABG module, record SSI. Submit a second record for the Cardiac module, no SSI

2. Do not submit to CABG module (excluded due to delayed closure). Submit to the Cardiac module, with SSI

3. Submit CABG record with 3 SSI. Submit second record for Cardiac module, no SSI

4. Do not submit CABG (excluded due to delayed closure). Submit to Cardiac module, with one SSI (but not the leg infections)

5. Submit to the CABG module, record one SSI (exclude leg SSIs, which are only recorded up to day 30). Submit a second record to Cardiac module, no SSI

6. Submit the CABG, no SSI (superficial only recorded up to day 30). Submit a second record for the Cardiac module, no SSI

7. Do not submit to the CABG module (excluded due to delayed closure). Submit to the Cardiac module, no SSI (superficial SSI excluded as >30 days onset).

8. Excluded (not to submit)- OPCS code for aortic root repair is not included in the Cardiac module

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