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