1
IP Call- June 13th
IP Call- June 13th
Good morning everybody. We will go ahead and get started this morning. Welcome to the June IP Call. Today, we are going to talk a little bit about SSI surveillance and reporting for NHSN and we will hear from Nancy Wilde. So I am right away just going to go ahead and hand this over to Nancy so we can go ahead and get started and then we will come back through and do your HEN,IDPH,and Telligen update. So hold on one second here. Nancy, I am going to hand this over to you. Are you on the call Nancy?
I am thank you. Alright. Can you see my…..
Hold on one second it is just have been over to you so.
Okay. Brand new computer today so it’s like little throwing me off. Is that working? Can you see my screen just now?
I am not seeing your screen. Were you able to see my screen before. Yeah, but now it has disappeared.
Okay. I can see that the sign on that I can see this people are there but I cannot see your. All I see is the IP call June 13.
It is not showing or something.
I tried to send you my presentation just in case this happen. Did you get that? Can you pull it up?
Yes, I can surely do that.
I was not trusting on my computer.
There we go.
Yeah, that’s working I can see it. There we go. Okay. We will go right into the second slide here were we are just going to review some surgical site information. We will click here and I understand that this is only an hour call so it will be, you will be surprised that how quick this is going to go. I am not going to go in the terms of detail but one of the priority here is I just want you to understands and I know you all do this that is why surgical sites surveillance is important and obviously when you look at number of infections SSIs and pneumoniasare two most commonly occurring HAIs and we are all looking at different aspects in healthcare. How you cut down on readmission, how you decrease hospitalization stays and when you see here that as a study by Merkow and Chung that SSIs account for 20% of unplanned readmissions after surgery. They also account for possibly 11 days on average for each SSI per patient. They are definitely an issue that your entire organization should be interested in. So if you will click to the next one. When you guys call me with questions on SSIs or any type of NHSN questions these are the types of things that I usually go to for answers. I want you to have a chance to see how many, these are the frequently asked questions and these are all brand new. They were just loaded up in April of 2016. These are based on a new definitions as of January so these are going to be some questions that you can go to if you have something pop up in your facility you may get your answer right and then there you can always call me but this is where a lot of times I go to for my information. If you have already that very top of the chapter identifying healthcare associated infections for NHSN surveillance, it is important that you have access to that and I personally print them off but I know a lot of you just bookmark those and just pull them up on your computer whenever you need to whether it works best for you but wanted you to understand that there is a lot of information out there that you can access. In the next couple of slides there is some additional information that you might want to look at, so if you are online go ahead uploading that on. Share again some of the data collection forms and I had a couple of errors that they did not translate on with a new addition so I do want you to notice that the table of instructions there under each one for every form there is, there is a table of instructions is that you can go to. If you don’t know what you are supposed to put on the line you can just open up the tablet of instructions specifically how to respond to each question so I actually used those a lot. When I get a question that I cannot answer, just wanted you to be aware that you can go on and look at that and the next slide. We do have people that are muted. If you want to go ahead then mute your line. You guys can go ahead and mute your lines. If you are not talking that would be helpful. Okay, this one also with a new changes as the ICD 10 just get you rest of the codes that you can look at getting some feedback. Somebody can mute their lines if that may be not muted. Okay. I am sorry. You can go ahead and go on to the next slide. I get a lot of questions especially from new IPs on what you need to be looking that and how you determine SSIs. So just for those if you may not have been doing this a long time the first thing that you want to do is to determine which surgical patients are going to follow and I know that a lot of the bigger hospitals have defined that pretty well. This is for some of the smaller facilities you really need to identify what is actually a surgical procedure, what is being done at your facility, what’s your priorities and which patients you are going to monitor and in a lot of critical access they want you to follow all of the patients that you may not be able to do that so you need to look at what’s being done in your facility and your risk assessmentif you do every year can help you work through and determine which surgical procedures are going to be looking at. So you determine whether or not somebody has an infection. One of the things that I found very helpful is admission logs when I see somebody coming in with an admitting diagnosis that I could look at and a lot of time if it was related to an infection or the postop surgical wound infection you could look at ER admissionis another one that you can review. You also want to get out and look at chart whenever you can talk to the staff, review nurses notes and physician notes but I think that priority there is suggest be aware of what’s going on in your hospital and we saw that the staff notes that they can talk to about things. So, going on to the next one. Someone there inpatient in the lobby is you are to look at that that post discharge SSI surveillance can be a little bit more tricky. Some of the things that work really well for a lot of hospitals is sending out a list to the surgeons and asking them to tell you whether or not somebody had had an infection when they come back in for your postop visit. That works really well for a lot of cases and most of you have pretty good reports at the physician offices and we are able to get information back in. Another thing that you can do is go look at and some of you have access to postop clinic records and obviously again looking at readmission and ED diagnosis but keep in mind that regardless of whether you are getting that information you do need to apply the criteria to determine whether an SSI is detected and sometimes you will get a response back from a physician that there was cellulitis, it is an infection. You may need to get additional information to know if it is going to need definition. So, don’t be afraid to communicate with the offices if they are seeing somebody in their clinic and they indicate that there was a problem with the wound. Oops, sorry. I guess I cannot go forward with the slide so if you go ahead and go to the next one. I wanted to just review a couple of thermologies or terms with you real quick. The NHSN operative procedure is used pretty frequently as to when you are deciding what you need to do so an NHSN operative procedure is got to be on the list, the CPT or the ICD 10 codes. I am kind of outdated there. It has to take place during an operation where there is an incision made even if there is a laparoscopic approach to the skin or mucous membrane and it has to take place in an operating room or an area that meets the definition of an operating room according to the American Institute of Architects. So that could be a C-section, could be an interventional radiology room, or cardiac cath room in addition to you regular operating room suite. So if you can go forward Jennifer. Present at the time of surgery so what’s that is saying is that there was infection at the time of the start or during the index surgical procedure. It is not found on the denominator form but that is the thing that you would mark if you are recording the surgical site either and there has to be definite evidence of infection or abscess noted in the operative note so you will need to look to see if that is the case. The advantage is that when you are reporting your denominator that is not a piece of information that you are going to have to collect. When that becomes an issue with when you are looking at an infection that gives you an opportunity to go into that surgical chart. So if you can go to the next slide. Actually there are three slides on the computer. One of the tricks here is that it’s only going to be responded that it was present at the time of surgery if the infection is the same level as a surgical site infection. So if you had somebody that had evidence of an intraabdominal abscess and two weeks after surgery they wind up walking and thrown off as they have a superficial incisional infection that does not count you would not mark that present at the time of surgery but it has to be at the same level of infection that was seen at the time of the surgical procedure. And that is how you report that. So when you report any event or just simply that little box there that you would mark present at the time of surgery and you do not have to apply any definition for that box itself but if they have documented infection and is the same level of infection you would mark that. So next slide please. Date of event is simply the date before the first element is used to meed that as site infection criteria for the first time during the infection surveillance. The first temperature, the first culture, the first time that wound is open so anything that is going to help me that definition that is the data of event. The next slide. I get this question often a lot with inpatient and outpatient for CMS rule, they are asking you to report inpatient procedures, some facilities in your risk assessment you are doing both inpatient and outpatient for certain surgery type that is how are your decision that how you define that is an inpatient operative procedure is one where the date of admission and date of discharge are on different calendar days. It does not make any difference if they are under an extended odds or if they are actually admitted to the floor if they come into your facility on one day, leave on the different day that is an inpatient procedure. Outpatient is when they are in and out on the same day. Next. Denominator data is you look at procedures done in one month to complete a denominator a procedure record for every operation of the types of codes that you are following and if it is in your reporting finally for every single one so if you do 20 colon procedures in a month and you are reporting on colon procedures you would use 20 denominator forms. They do ask if you do that in a timely manner and the denominator information is actually much easier to get in in a timely manner, but sometimes because of the surveillance period this is harder to get events insert in but as you do have to wait until the 30 day or 90 day periods if surveillance period is over that is for the denominator data you should be able to get that in a pretty timely manner. So we will go through the next. Some other things on the procedures that can be difficult to get if you are trying to look at as you are doing your chart review. I just wanted to touch base on a couple of things. There are a lot of you that are able to pull information from your electronic medical record to drop into a spreadsheet. Some of you don’t have that ability to do that. Wound class is one of those things that can be a challenge on your denominator procedure. It is required for every procedure that you are reporting. You identify whether it is clean, clean contaminated, contaminated, or dirty. We used to call those 1, 2, 3 and 4. The wound class should be done at the time of procedure, and it is usually performed and assigned by somebody who is actually in the operating room, the scrub nurse or circulating nurse. It is not usually something that has to be done by the IP. Although if you see something that does not make sense, I would go back to them and we saw lot of hysterectomies that would be coded as clean and you cannot enter the vagina INAUDIBLE17:28 all cavity. So, this should always contaminated of that. Going to the next.
This is another and I just kind of mentioned to you that the outpatient procedure at your facility, at least overnight there are going to be an inpatient if not then it will be outpatient. Probably, the trickiest piece of information to get when you are pulling those records is duration of the procedure that needs to be done in hours and minutes. It is rather tense when you are looking at the chart and you get a start time and a stop time and it is not usually recorded in hours or minutes so that is something a lot of times. It is difficult to calculate or to pull from the record. Going on to the next slide.
I am hoping that it all make sense anyway. I thought that was kind of INAUDIBLE18:34, it may be give a little bit of face and maybe we will all make it through the all of the reporting this coming on field from NHSN. So, we will go ahead and go onto the next.
Thank you, so there are three different levels of surgical site infection. The first one is superficial incisional SSI and that occurs within 30 days after any NHSN operative procedure if only thing involved is skin and subq tissue. They have to have either purulent drainage or organisms obtained from asepticallyobtained specimen and what NHSN tells me basically is that if it is something that in a physician’s office or in the clinic and they are doing that, they using the swab, you would consider that as an aseptically obtained specimen. So, you do not need to try to identify how that is done. So going through the next.
If the physician is deliberately opinion and they will as long as it is not culture negative. So if they did a culture and it does not grow anything the fact that they open that does not meet that criterion, but if they open it and do not culture it and that can meet that. In addition to that, they also have to have some signs and symptoms of pain, tenderness, localized swelling, erythema or heat, or/and for superficial incision if it is diagnosis by the surgeon or attending physician or the designate can meet the definition of the superficial incisional infection. So, moving on.
Just a word of caution here. We get a lot of reports that somebody has cellulitis after the incision and that itself is not considered in SSI; if draining and has a positive culture, it is not considered cellulitis. Even though the physician may say that it does simply a reddened incision with diagnosis of cellulitis does not meet the definition of a surgical site infection. Also, a lot of times, there will be just a little small stitch abscess with minor inflammation and that is not considered as surgical site or stab wound is not considered a surgical site. Now, a laparoscopic trocar site or stab wound is considered an operative procedure, so you would count that.
This is the chart in your definitions that you can ask and it does talk about whether or not the procedure should be monitored for 30 days or 90 days. I know you have all seen this. The majority of the procedures that you are looking of colons and hips are going to be in that 30 days. Your total joints for knees and hips and hernia is another one that falls under the 90-day procedure. Now, if it is a superficial incisional, you are only going to follow superficial incisional infections for 30 days. So even if it is on that 90-day chart if it is superficial, it is not going to count if it is after that first 30 days. Going on the next.
The monthly reporting plans are very important as you are setting this up and I should have this slide there a little bit. Determining what you are going to follow is important and then making sure that you have this established. You are going to report superficial deep and organ space infection and I can say usually how much your reporting sense makes a difference in what you are reporting and how it shows out. So, if there is an issue with your data, I usually go to the reporting plan first and find out if it is bit something in the way you are reporting INAUDIBLE22:52, so. If you want to go to the slide, we will just keep going.