Surveillance of Surgical Site Surveillance of Surgical Site InfectionInfection
An overview of results (2004)
Jennie WilsonJennie WilsonProgramme Lead – SSI surveillance Service, EnglandProgramme Lead – SSI surveillance Service, England
Hospitals in Europe Link in Infection Control through Surveillance
SSI surveillance protocolSSI surveillance protocol
Patient level datasetPatient level dataset NNIS risk indexNNIS risk index Type of procedureType of procedure Age/sexAge/sex
CDC definition for SSICDC definition for SSI Micro-organism data optionalMicro-organism data optional
Surveillance methods – potential variationSurveillance methods – potential variation Intensity of case-findingIntensity of case-finding Post-discharge surveillancePost-discharge surveillance Interpretation of definitionsInterpretation of definitions
Participation in HELICS SSIParticipation in HELICS SSI
ProceduresNo. operations No. countries2000-3 2004 2000-3 2004
CABG 28 453 12 234 7 8
Cholecystect. 30 225 16 380 8 8
Colon 20 798 10 778 9 9
C section 30 035 19 580 9 8
Hip prosthesis 59 274 49 496 11 14
Laminectomy 3 142 2 913 4 6
Total 171 927 111 361 13 14
The HELICS Network of Networks (2004)The HELICS Network of Networks (2004)
Austria
314
LuxembourgICU network
Netherlands
6225
France
16 560
Spain
2854
Portugal
ICU network
Belgium
588
England
24910
Northern Ireland
2001
Wales
472
Scotland
5182
Finland
2854
Norway
SSI network
Poland
6766
Germany
40 437
Lithuania
3340
Humgary
669
Proportion of countries’ hospitals Proportion of countries’ hospitals contributing data to HELICScontributing data to HELICS
0
10
20
30
40
50
60
70
%
EN PL NL LT HU FR FI ES DE BE AT
Case-mix adjustment: NNIS Risk IndexCase-mix adjustment: NNIS Risk Index
0%
2%
4%
6%
8%
10%
12%
CABG CHOL COLO CSEC HPRO LAM
Cu
mu
lati
ve In
cid
ence
NNIS 0
NNIS 1
NNIS 2/3
NNIS Unknown
Distribution of risk Index by countryDistribution of risk Index by countryHip prosthesisHip prosthesis
020
4060
8010
0
AT BE DE ES FI FR HU LT NL PL UE UN US UW
HPRO
NNIS 0 NNIS 1 NNIS 2 NNIS 3
Per
cent
age
of o
pera
tion
s
Type of SSI reported: Type of SSI reported: Hip prosthesisHip prosthesis
020
4060
8010
0
AT BE DE ES FI FR HU LT NL PL UE UN US UW
HPRO
Superficial incisional Deep incisional Organ/space
Per
cent
age
of S
SI
No SSI 4 24 200 13 132 36 5 1 120 39 378 32 64 10
Median post-operative length of Median post-operative length of hospital stay & inter-country variationhospital stay & inter-country variation
0
2
4
6
8
10
12
14
Da
ys
CABG CHOL COLO CSEC HPRO LAM
Post-discharge surveillancePost-discharge surveillance
Not a requirement in all countriesNot a requirement in all countries Variation in PDS intensityVariation in PDS intensity Application of case definitionsApplication of case definitions
Proportion of SSI detected after Proportion of SSI detected after dischargedischarge
% SSI detected after discharge (Inter-country range*)
CABG 10 0 - 47
0 - 100
0 - 33
0 - 83
13 - 100
58 - 100
CHOL 31
COLO 12
CSEC 53
HPRO 20
LAM 50
* Excludes 4 countries where PDS data not available/collected
Daily incidence rate of SSIDaily incidence rate of SSI (all procedures) (all procedures)
0
1
2
3
1-5 6-10 11-15 16-20 21-25
Days after surgery
Dai
ly i
nci
den
ce /
1000
Rates (cumulative incidence) of SSI Rates (cumulative incidence) of SSI by surgical category (95%CL)by surgical category (95%CL)
0%
2%
4%
6%
8%
10%
CABG CHOL COLO CSEC HPRO LAM
Cu
mu
lati
ve In
cid
ence
0
5
10
15
20
CABG CHOL COLO CSEC HPRO LAM
Cu
mu
lati
ve
inc
ide
nc
eCumulative incidence of SSI
by category (inter-country
range)
Incidence density of SSI by category
(inter-country range)
0
4
8
12
16
CABG CHOL COLO CSEC HPRO LAM
Inci
den
ce d
ensi
ty
Comparison of cumulative incidence and Comparison of cumulative incidence and incidence density for hip prosthesisincidence density for hip prosthesis
0
2
4
6
8
10
12
14
1
Inci
den
ce D
ensi
ty (
/100
0)
BE ES FI HU UK-E NL UK-N UK-S UK-W AT FR
02468
101214161820
1
Cu
mu
lati
ve I
nci
den
ce (
%)
BE FI AT ES HU NL FR UK-E UK-S UK-W UK-N
Potential impact of case-mixPotential impact of case-mix
Cumulative incidenceCumulative incidence Incidence Incidence densitydensity
% SSI at 30 days % SSI at 30 days post-oppost-op
In-hospital SSI per In-hospital SSI per 1000 post-op days1000 post-op days
All hip prosthesis 2.2 1.8 Total hip (81.51) 1.6 1.7
Partial hip (81.52) 4.0 2.2
Example: ICD9 CM codes for Hip replacements
Inter-country variation in type of Inter-country variation in type of hip procedurehip procedure
020
4060
8010
0P
erce
ntag
e of
ope
ratio
ns
with
in H
PR
O
BE DE ES FI HU PL UK-EN UK-NI UK-SCUK-WA
81.51 Total hip replacement81.52 Partial hip replacement81.53 Revision of hip replacement
ConclusionsConclusions
It’s complicated!It’s complicated!
…….but valuable.but valuable
LimitationsLimitations
Differences in patient and operation Differences in patient and operation characteristics characteristics
Risk indexRisk index Age Age Procedure type Procedure type
Differences in case findingDifferences in case finding Type of SSIType of SSI
Differences in length of inpatient stayDifferences in length of inpatient stay PDS – intensityPDS – intensity Discharge dataDischarge data
OpportunitiesOpportunities
Large datasetLarge dataset Includes PDS dataIncludes PDS data Explore relationships with time post-opExplore relationships with time post-op Develop risk modelsDevelop risk models Useful comparatorsUseful comparators
Common protocol a major achievementCommon protocol a major achievement Framework to encourage SSI surveillanceFramework to encourage SSI surveillance Need to enhance Need to enhance
micro datamicro data PDSPDS Procedure codesProcedure codes
AcknowledgementsAcknowledgements HELICS data analysis group, especially Ilse Ramboer HELICS data analysis group, especially Ilse Ramboer
and Carl Suetensand Carl Suetens Surveillance networks & their co-coordinatorsSurveillance networks & their co-coordinators