Surgical Site Infection Improvement Programme frequently asked questions
Surgical Site Infection Improvement Programme frequently asked questions
A surgical site is the incision or cut in the skin made by a surgeon to carry out a surgical procedure. The position and size of the surgical site depends on the intended procedure and the type of surgery.
A surgical site infection (SSI) can occur when bacteria from the skin, other parts of the body or the environment enter the incision made by the surgeon and multiply in the tissues. This causes physical symptoms as the body tries to fight the infection, such as pus, inflammation, swelling, pain and fever.
Surgical antimicrobial prophylaxis is the use of antibiotics to reduce the risk of SSI. This is an evidence-based SSI prevention strategy for patients undergoing surgical procedures such as hip and knee arthroplasty and cardiac surgery. It involves using the five ‘Rs’ of medication safety; right patient, right antibiotic, right dose, right time, and the right duration. For more information you can read the SSI Improvement Programme’s Surgical antimicrobial prophylaxis intervention guidelines.
Preoperative skin antisepsis is a simple and effective measure to reduce the risk of surgical site infections (Maiwald, 2012). The primary source of organisms contributing to infection following surgery is the bacteria on a patient’s skin. The aim of skin antisepsis is to eliminate and rapidly kill skin flora at the site of a planned surgical incision (Safer Healthcare Now, 2011). For more information you can read the SSI Improvement Programme’s Surgical skin antisepsis preparation intervention guidelines.
International evidence demonstrates that when preoperative hair removal is required clipping, not shaving is the best approach to reduce the risk of SSIs. Shaving with a razor can cause micro-abrasions on the skin, from which microorganisms can proliferate and colonize, contaminating the incision site. Clipping hair immediately before an operation has been associated with a lower risk of SSI.
For more information you can read the SSII Programme’s Clipping not shaving intervention guidelines.
District health boards (DHBs) collect data about hip and knee arthroplasty surgery on an ongoing basis. This enables the SSI Improvement Programme and DHBs to provide feedback and advice to surgical teams regarding improvements to clinical practice to reduce the risk of SSI.
Surgical procedure categories were introduced into the SSI Improvement Programme in a staged approach. The first stage focused on hip and knee arthroplasty surgeries in which data has been collected from DHBs since mid-2013. The second stage focused on cardiac procedures which began in mid-2016. The programme is currently being evaluated to determine the next areas of focus for the programme.
Definitions of SSI can be found in the SSI Improvement programme orthopaedic implementation manual and the SSI Improvement programme cardiac implementation manual. These can be downloaded from the Commission’s website.
You should discuss the case with the clinical microbiologist or infectious diseases physician at your DHB, or alternatively with the operating surgeon. You may need to have the definition with you when you do this as surveillance definitions can be different to the clinical definitions that are used.
Alternatively please email ICNetSupport@cdhb.health.nz or SSIIP@hqsc.govt.nz to discuss the case.
No, only if other criteria are present as well, such as spontaneous dehiscence of the wound. See the definitions section in the SSI Improvement Programme implementation manual, the SSI Improvement Programme cardiac implementation manual and the SSI Improvement Programme orthopaedic implementation manual for more information.
The 2012 New Zealand Operating Standards for Ethics Committees states that, in general, monitoring of care does not require ethics committee review. However, it is important that health care workers participating in observational research and audits, and other activities related to observational research such as quality assurance activities, operate under the same professional standards and confidentiality requirements as the individual caregiver.
Post-operative antibiotic prophylaxis refers to the three doses of cefazolin given at eight-hourly intervals after the procedure is complete. For example, three doses of cefazolin given post-operatively at eight hourly intervals. Usually the first dose is given shortly after the completion of the operation, the second eight hours later and the third a further eight hours after the second dose. However, the administration of the first of these three doses may be delayed. If this is the case and the third dose is administered just after the 24-hour time period, then that is considered acceptable and the question on the electronic data collection form (antibiotics given for <24hours) can be answered YES.
If more than three doses are administered, then it will exceed the 24-hour time period. For the question about post-operative antibiotic ‘were they given post- operatively?’ record YES and for the question ‘If yes, were they given for ≤ 24 hours?’ record NO. More information is available in the surgical antimicrobial prophylaxis intervention guidelines.
Femoral block for pain relief is not sufficiently important to record for the SSI data collection purposes. If a patient receives either regional or spinal anaesthetic the femoral block can be ignored. Please just record epidural or spinal.
The American Society of Anaesthesiologists (ASA) score is used as part of the National Healthcare Safety Network (NHSN) risk score along with wound class and length of procedure. The risk score is an important item as it is the only way we have of adjusting rates for different risk categories so we can compare similar patient groups.
You can close the case at 30 days but it can be retrieved, re-opened and amended if a standard SSI case occurs up to 90 days post procedure. You can retrieve the form from the SSII Programme’s online data collection website (national monitor) by entering the patient's national health index number.
All DHBs should capture the procedures that they fund regardless of where the procedure is performed. As long as the patient remains in an inpatient unit in a DHB, you should keep them logged as an inpatient and monitor for any infection. This includes patients who move from acute services to rehabilitation services. Inpatient surveillance should finish when the patient is finally discharged.
A patient may have a number of readmissions in the 90 days post-operatively. If they are clearly suspected of having an infection in their surgical site, you should record the readmission date as the date of the first admission where infection was suspected. As long as subsequent readmissions appear to relate to this infection, the initial readmission date is sufficient.
Infections outside of this time period are not captured in this programme but there may be some learning from such a case, for example, delay in diagnose is due to oral antibiotic use in the community. If a patient is readmitted shortly after the 90 day period after their initial surgery has passed, then it is important to establish when the first signs of infection became apparent. This case may need to be discussed with the surgical team or with the infectious diseases or clinical microbiology service.
This can be confusing. When a patient has an infected prosthetic joint replacement, one of the management strategies is a two-stage exchange procedure. In the first stage procedure the infected metal-ware is removed, the infected tissue debrided and the wound bed washed out. The patient then receives a prolonged course of systemic antibiotics after which a new prosthetic joint is implanted; the second stage of the two-stage exchange.
The first stage procedure is for the management of infection, it does not count as a procedure. However, the second stage involves the implantation of a new prosthesis. This procedure counts as a new operation and is entered as a revision procedure and thus becomes part of the denominator data.
The following reference provides a useful review of this topic: Del Pozo JL, Patel R. Infection associated with prosthetic joints. NEJM 2009;361:787-94.
You should liaise with both surgical and anaesthetic services. It is important that they are aware that this information forms a quality marker for this programme, and you should work with them to find a way to capture it. Discuss the project with the theatre charge nurse and ask for their help with data collection.
Another approach is to identify the orthopaedic nurse specialist who looks after the New Zealand Orthopaedic Association Joint Registry in your DHB and see if they can help you find a solution.
This information forms the basis of a quality measure that will be reported to the Health Quality & Safety Commission, so it is very important.
If you cannot login to the online form for any reason, please contact the ICNet support team via email: ICNetSupport@cdhb.health.nz.
Please do not contact ICNet directly. All SSI Improvement Programme enquiries must be logged via the SSI Improvement Programme team and where required we will liaise with ICNet on your behalf.
There is a list of codes pre-loaded into the SSI Improvement Programme online data collection form. You can keep a record separately of who you allocate each code to. This way, only you will know who your surgeons are in relation to the number/code on the form.
A DHB light surveillance user recently noted an issue when importing an MS Excel CSV file into ICNet and the date format reverting to d/mm/yyyy when imported.
To format the date correctly as 01/08/2021 when importing to SSIS from a csv file, please format the date via the following method in excel.
Highlight all 3 date columns in the spreadsheet by holding the control key and clicking the letter of the column. Once highlighted right click over the highlighted area and select format. A pop-up will show (as per screenshot). Select d/mm/yyyy from the custom category, click into the text field under Type and edit this to dd/mm/yyyy. This enforces the preceding d in the date format and correctly populates as 01-08-2021.
Save the file as a csv as per previous and import following usual processes.
The above instructions have been added as an addendum to the Data Collection Elements Document, which is hosted on the CHDB SharePoint Site under SSIS Programme -> Light Surveillance.
If there any issues with this process please raise an iSupport Ticket with the title ‘Light Surveillance – Date Format’.
If there are any Light Surveillance users missing from this email please forward this email and cc: Pip Hawker Phyllipa.Hawker@cdhb.health.nz.
What is a surgical site and how can an infection occur?
A surgical site is the incision or cut in the skin made by a surgeon to carry out a surgical procedure. The position and size of the surgical site depends on the intended procedure and the type of surgery.
A surgical site infection (SSI) can occur when bacteria from the skin, other parts of the body or the environment enter the incision made by the surgeon and multiply in the tissues. This causes physical symptoms as the body tries to fight the infection, such as pus, inflammation, swelling, pain and fever.
What is the antibiotic prophylaxis intervention?
Surgical antimicrobial prophylaxis is the use of antibiotics to reduce the risk of SSI. This is an evidence-based SSI prevention strategy for patients undergoing surgical procedures such as hip and knee arthroplasty and cardiac surgery. It involves using the five ‘Rs’ of medication safety; right patient, right antibiotic, right dose, right time, and the right duration. For more information you can read the SSI Improvement Programme’s Surgical antimicrobial prophylaxis intervention guidelines.
What is the skin preparation intervention?
Preoperative skin antisepsis is a simple and effective measure to reduce the risk of surgical site infections (Maiwald, 2012). The primary source of organisms contributing to infection following surgery is the bacteria on a patient’s skin. The aim of skin antisepsis is to eliminate and rapidly kill skin flora at the site of a planned surgical incision (Safer Healthcare Now, 2011). For more information you can read the SSI Improvement Programme’s Surgical skin antisepsis preparation intervention guidelines.
What is the clipping not shaving intervention?
International evidence demonstrates that when preoperative hair removal is required clipping, not shaving is the best approach to reduce the risk of SSIs. Shaving with a razor can cause micro-abrasions on the skin, from which microorganisms can proliferate and colonize, contaminating the incision site. Clipping hair immediately before an operation has been associated with a lower risk of SSI.
For more information you can read the SSII Programme’s Clipping not shaving intervention guidelines.
How long will data collection for hip and knee arthroplasty surgery last?
District health boards (DHBs) collect data about hip and knee arthroplasty surgery on an ongoing basis. This enables the SSI Improvement Programme and DHBs to provide feedback and advice to surgical teams regarding improvements to clinical practice to reduce the risk of SSI.
What other surgical procedures does the SSII Programme cover?
Surgical procedure categories were introduced into the SSI Improvement Programme in a staged approach. The first stage focused on hip and knee arthroplasty surgeries in which data has been collected from DHBs since mid-2013. The second stage focused on cardiac procedures which began in mid-2016. The programme is currently being evaluated to determine the next areas of focus for the programme.
Where can I find the definitions of infection?
Definitions of SSI can be found in the SSI Improvement programme orthopaedic implementation manual and the SSI Improvement programme cardiac implementation manual. These can be downloaded from the Commission’s website.
What if I cannot decide if a patient fits the criteria for an SSI?
You should discuss the case with the clinical microbiologist or infectious diseases physician at your DHB, or alternatively with the operating surgeon. You may need to have the definition with you when you do this as surveillance definitions can be different to the clinical definitions that are used.
Alternatively please email ICNetSupport@cdhb.health.nz or SSIIP@hqsc.govt.nz to discuss the case.
Does redness or cellulitis alone count as infection?
No, only if other criteria are present as well, such as spontaneous dehiscence of the wound. See the definitions section in the SSI Improvement Programme implementation manual, the SSI Improvement Programme cardiac implementation manual and the SSI Improvement Programme orthopaedic implementation manual for more information.
Do we need to get ethical approval to collect this information from patient records?
The 2012 New Zealand Operating Standards for Ethics Committees states that, in general, monitoring of care does not require ethics committee review. However, it is important that health care workers participating in observational research and audits, and other activities related to observational research such as quality assurance activities, operate under the same professional standards and confidentiality requirements as the individual caregiver.
What happens if the post-operative cefazolin is completed after 24 hours?
Post-operative antibiotic prophylaxis refers to the three doses of cefazolin given at eight-hourly intervals after the procedure is complete. For example, three doses of cefazolin given post-operatively at eight hourly intervals. Usually the first dose is given shortly after the completion of the operation, the second eight hours later and the third a further eight hours after the second dose. However, the administration of the first of these three doses may be delayed. If this is the case and the third dose is administered just after the 24-hour time period, then that is considered acceptable and the question on the electronic data collection form (antibiotics given for <24hours) can be answered YES.
If more than three doses are administered, then it will exceed the 24-hour time period. For the question about post-operative antibiotic ‘were they given post- operatively?’ record YES and for the question ‘If yes, were they given for ≤ 24 hours?’ record NO. More information is available in the surgical antimicrobial prophylaxis intervention guidelines.
On the data collection form in the section that covers anaesthetic, there is no place to enter if a patient has had a spinal or epidural and a femoral block.
Femoral block for pain relief is not sufficiently important to record for the SSI data collection purposes. If a patient receives either regional or spinal anaesthetic the femoral block can be ignored. Please just record epidural or spinal.
Why is it so important to record the ASA score?
The American Society of Anaesthesiologists (ASA) score is used as part of the National Healthcare Safety Network (NHSN) risk score along with wound class and length of procedure. The risk score is an important item as it is the only way we have of adjusting rates for different risk categories so we can compare similar patient groups.
When do I close off the form – at 30 or 90 days?
You can close the case at 30 days but it can be retrieved, re-opened and amended if a standard SSI case occurs up to 90 days post procedure. You can retrieve the form from the SSII Programme’s online data collection website (national monitor) by entering the patient's national health index number.
A patient had a knee replacement, was transferred to a specialist rehab unit in a different hospital for a number of days and then transferred back to our hospital. At no point was he discharged. At what point do I stop the inpatient surveillance?
All DHBs should capture the procedures that they fund regardless of where the procedure is performed. As long as the patient remains in an inpatient unit in a DHB, you should keep them logged as an inpatient and monitor for any infection. This includes patients who move from acute services to rehabilitation services. Inpatient surveillance should finish when the patient is finally discharged.
If a patient is readmitted multiple times within the 90 days, which date do I enter?
A patient may have a number of readmissions in the 90 days post-operatively. If they are clearly suspected of having an infection in their surgical site, you should record the readmission date as the date of the first admission where infection was suspected. As long as subsequent readmissions appear to relate to this infection, the initial readmission date is sufficient.
What happens if a patient returns more than 90 days after surgery with an infection?
Infections outside of this time period are not captured in this programme but there may be some learning from such a case, for example, delay in diagnose is due to oral antibiotic use in the community. If a patient is readmitted shortly after the 90 day period after their initial surgery has passed, then it is important to establish when the first signs of infection became apparent. This case may need to be discussed with the surgical team or with the infectious diseases or clinical microbiology service.
When a patient undergoes a two-stage procedure for the treatment of infection are these operations counted?
This can be confusing. When a patient has an infected prosthetic joint replacement, one of the management strategies is a two-stage exchange procedure. In the first stage procedure the infected metal-ware is removed, the infected tissue debrided and the wound bed washed out. The patient then receives a prolonged course of systemic antibiotics after which a new prosthetic joint is implanted; the second stage of the two-stage exchange.
The first stage procedure is for the management of infection, it does not count as a procedure. However, the second stage involves the implantation of a new prosthesis. This procedure counts as a new operation and is entered as a revision procedure and thus becomes part of the denominator data.
The following reference provides a useful review of this topic: Del Pozo JL, Patel R. Infection associated with prosthetic joints. NEJM 2009;361:787-94.
What if I can't get the antibiotic prophylaxis information required on the form?
You should liaise with both surgical and anaesthetic services. It is important that they are aware that this information forms a quality marker for this programme, and you should work with them to find a way to capture it. Discuss the project with the theatre charge nurse and ask for their help with data collection.
Another approach is to identify the orthopaedic nurse specialist who looks after the New Zealand Orthopaedic Association Joint Registry in your DHB and see if they can help you find a solution.
This information forms the basis of a quality measure that will be reported to the Health Quality & Safety Commission, so it is very important.
I’ve forgotten my username and/or password to login to the SSI Improvement Programme online data collection form. What should I do?
If you cannot login to the online form for any reason, please contact the ICNet support team via email: ICNetSupport@cdhb.health.nz.
Please do not contact ICNet directly. All SSI Improvement Programme enquiries must be logged via the SSI Improvement Programme team and where required we will liaise with ICNet on your behalf.
Can I anonymise surgeon codes in my DHB?
There is a list of codes pre-loaded into the SSI Improvement Programme online data collection form. You can keep a record separately of who you allocate each code to. This way, only you will know who your surgeons are in relation to the number/code on the form.
Importing CSV files into ICNET– date format error
A DHB light surveillance user recently noted an issue when importing an MS Excel CSV file into ICNet and the date format reverting to d/mm/yyyy when imported.
To format the date correctly as 01/08/2021 when importing to SSIS from a csv file, please format the date via the following method in excel.
Highlight all 3 date columns in the spreadsheet by holding the control key and clicking the letter of the column. Once highlighted right click over the highlighted area and select format. A pop-up will show (as per screenshot). Select d/mm/yyyy from the custom category, click into the text field under Type and edit this to dd/mm/yyyy. This enforces the preceding d in the date format and correctly populates as 01-08-2021.
Save the file as a csv as per previous and import following usual processes.
The above instructions have been added as an addendum to the Data Collection Elements Document, which is hosted on the CHDB SharePoint Site under SSIS Programme -> Light Surveillance.
If there any issues with this process please raise an iSupport Ticket with the title ‘Light Surveillance – Date Format’.
If there are any Light Surveillance users missing from this email please forward this email and cc: Pip Hawker Phyllipa.Hawker@cdhb.health.nz.
