Welcome to the National Healthcare Safety Network, or
NHSN, Hot Topic Session. This presentation is a review
of updates to the Surgical Site Infection, or SSI,
protocol for 2015.
This presentation only focuses on changes to the
protocol; it does not cover the entire SSI protocol.
The full protocol is located on the NHSN website.
Since 2013, NHSN has been gradually implementing
recommendations from the Healthcare Infection Control
Practices Advisory Committee, or HICPAC, SSI working
group. The goal of these changes to the SSI Protocol is
to bring NHSN definitions in line with those from other
surgical professional organizations. HICPAC
recommendations were based on input from:
Infection Preventionists, CDC, AORN, ACS, STS,
ACOG And AAOS
The first change involves a new PATOS field, which
stands for infection present at the time of surgery.
PATOS is a required field and is found on the SSI
event form, not on the denominator for procedure form.
Do not select this field if a patient had a history of
an infection but there was a period of wellness between
the time of the pre-operative condition and surgery.
To select this field on the SSI form, evidence of
infection must be documented peri-operatively or found
intra-operatively in a pre-op or intra-op note.
Only Select Yes for the PATOS field on the SSI form if
it applies to the depth of the SSI that is being
attributed to the procedure. We will review some
examples in the next slide. The patient does not have
to meet the NHSN definition of an SSI at the time of
the primary procedure, but evidence of infection or
abscess present at the time of surgery must be noted.
We will present three examples of how to answer the
PATOS field question. In the first example, a patient
is admitted with an acute abdomen. In the OR, during
the exploratory laparotomy, there are findings of an
abscess due to a ruptured appendix. An appendectomy is
performed. The patient returns two weeks later and
meets criteria for an organ space Intra-abdominal SSI.
You would select Yes for the PATOS field on the SSI
event form. In the second example, a patient is
admitted with a ruptured diverticulum and in the
operative note; the surgeon reports multiple abscesses
in the intra-abdominal space. The patient returns three
weeks later and meets criteria for a superficial
incisional SSI. You would select No for the PATOS
field. There was no documented evidence of
infection or abscess of the skin or subcutaneous area
at the time of the procedure.
In the third example, during an unplanned cesarean
section, the surgeon nicks the bowel and there is
contamination of the intra-abdominal cavity. One week
later the patient returns and meets criteria for an
organ space other reproductive SSI. You would select No
for the PATOS field. There was no documented evidence
of infection or abscess at the time of the c-section.
The colon nick was a complication but there was no
infection present at the time of surgery.
The next update to the SSI protocol is related to hip
arthroplasty, or HPRO, and knee arthroplasty, or KPRO,
revision procedures. Not all facilities follow these
in their surveillance reporting plan. But if you
do, there are some changes. The new field asks, "Was
the revision associated with prior infection at index
joint?" This field is on the denominator for procedure
entry form for revision procedures.
If a total or partial HPRO or KPRO revision is
performed, evaluate to determine if certain ICD9-CM
diagnosis or associated procedure codes were entered.
You would review 90 days prior to and including the
index revision procedure. If any of the specified codes
on the next slide are recorded, select Yes for the data
field question "Was the revision associated with prior
infection at index joint?" It's not necessary to review
the medical record for additional details concerning
the prior infection. This variable is defined by the
presence of one or more of the ICD9-CM codes associated
with the index HPRO or KPRO revision procedure in the
90-day pre-operative period. If the original HPRO or
KPRO was performed at an outside facility, the ICD9-CM
codes won't be available and only codes for the index
revision case should be assessed.
If any of these ICD9-CM codes are found in the patient's
coded record you will answer Yes to this new field.
NHSN is collecting these two new SSI data fields to
enhance reporting for all HAI data. NHSN will
re-baseline all HAIs based on 2015 data. New data reported
to NHSN will provide the baseline for calculating
Standardized Infection Ratio's or SIRs for 2016 and
subsequent years. SIRs calculated for 2015 data will
use the current baselines.
SSIs reported with PATOS as a Yes will be excluded
from SSI SIRs beginning with 2016 data and the new
baseline. These excluded SSIs will be available for
analysis by the facility.The prior infection at index joint
field will be used as a new risk factor. It will be considered
in the risk adjustment models for new HPRO and
KPRO 2015 baselines.
In 2015, NHSN is providing a second method that can be
used to answer the diabetes field question. Assignment of
the discharge ICD9-CM codes in the 250 to 250.93 range
is acceptable for answering Yes to the diabetes field question.
NHSN has updated definitions of inpatient and outpatient
procedures to answer the outpatient field on the SSI event
and the denominator for procedure forms. This definition
is no longer based on the patient being admitted and
discharged on different calendar days. If the OR suite is
largely intended for patients who will be admitted to an
inpatient unit, then all the procedures from this OR suite
will be considered inpatient procedures. The 80/20 rule
for mapping locations does not apply for determining the
inpatient OR suite status. For example if an inpatient OR
suite is largely intended for procedures performed on
patients admitted to the hospital, all procedures performed
in this OR area will be considered inpatient procedures.
This is true even if some of the patients having procedures
are not admitted to the hospital and do not spend a night.
If the OR suite is largely intended for procedures on patients
who will be not be admitted to an inpatient unit, then all of
the procedures from the OR suite will be considered outpatient
procedures. This is true, even if some of the patients have
procedures and spend a night in the hospital.
If the facility has only one OR area and performs all inpatient
and outpatient procedures in this area, it should be considered
an inpatient OR. All procedures performed in this area should
be reported as inpatient procedures.
In 2015 the reporting instruction for answering the scope risk
factor field on the denominator for procedure form has been
updated. NHSN had stated that if a trocar site was extended,
then the answer to the Scope question should be Scope
equals No. This reporting instruction has been removed. The
new reporting instruction found in the Table of Instructions is:
Check Yes if an NHSN operative procedure is coded as a
laparoscopic procedure performed using a laparoscope or
robotic assist, otherwise check No.
The definition of primary closure of an incision has been
simplified. The new definition states that a Primary Closure is
defined as closure of the skin during the original surgery,
regardless of the presence of wires, wicks, drains, or other
devices or objects extruding through the incision. This
category includes surgeries where the skin is closed by
some means. Thus, if any portion of the incision is closed at
the skin level, by any manner, a designation of primary closure
should be assigned to the surgery. This change removed the
phrase "all tissue levels" from the definition. This phrase caused
a lot of questions and confusion. This definition will be easier
to apply and is closer to definitions used by other surgical
professional groups.
For the non-primary closure definition found in the SSI protocol
the only change was the removal of this one sentence. "If the
deep fascial levels of an incision are left open but the skin is
closed, this is considered a non-primary closure since the
incision was not closed at all tissue levels." This sentence
was removed since this scenario would now meet the
primary closure definition.
On review NHSN noted that the current list of ICD-9 CM
codes for appendectomy procedures does NOT include
the code for incidental appendectomies. Therefore in
2015 do NOT report incidental APPY procedures since this
code is not in the current APPY ICD-9 CM procedure group.
Just a reminder that when an organ space SSI is evaluated,
you must meet one of the criteria for the general organ
space definition found in SSI protocol. In addition, you must
meet at least one criterion for a site specific organ space
infection site as listed in Table 4 in the SSI protocol.
For example, if a CT scan is performed and they see what
may be an intra-abdominal abscess, the IP must determine
if the case meets the definition of an IAB infection. These
site specific definitions are found in chapter 17.
All the definitions in the surveillance definitions chapter were reviewed
and updated for 2015. Please be sure to use the new definitions
in this section for applying organ space SSI criteria.
For 2015, CMS has not added any new NHSN operative
procedures. COLO and HYST procedures are still the only
two that are reported for acute care facilities participating in
the CMS Hospital Inpatient Quality Reporting Program and for
PPS-Exempt Cancer Hospital Quality Reporting Program.
CDC continues to work on updated ICD-10-CM/PCS and CPT
mappings to all NHSN operative procedure categories for SSI
surveillance. These mappings are anticipated to be available
by March 2015. ICD-10-CM PCS codes will replace ICD-9-CM
codes on October 1, 2015. However, NHSN will not have the
ability to receive these codes until the January 2016 release.
The NHSN guidance for entry of surgical denominator data
for the last quarter of 2015 is to enter the NHSN Procedure
Code, for example COLO or HYST. Do not enter any
ICD-10-CM/PCS codes associated with the procedure.
This concludes the NHSN Hot Topic update focusing on the
Surgical Site Infection protocol for 2015. If you have questions
please contact NHSN user support at NHSN@cdc.gov.