SSI Surveillance

Definition 

• Infection occuring within 30 days after surgery ( or 90 days if there is implant or prosthesis)

• CDC definition for surveillance of HAIs 2014

Why do surveillance?• Important clinical and economic impacts• Surgical site infections (SSIs) are the third most 

common form of healthcare‐associated infection (HAI), behind urinary tract (27%) and lower respiratory tract (24%) infections, comprising 17% of cases .

• The economic impact of SSIs is considerable, with an estimated burden on European healthcare providers of €7 billion in 2008. 

• Costs are driven predominantly by increased length of hospital stay, estimated to be an average 9∙8‐day increase compared to patients not experiencing a SSI.

Lamarsalle et al. Evaluating the clinical and economic burden of healthcare‐associated infections during hospitalization for surgery in FranceEpidemiol. Infect. (2013), 141, 2473–2482.

• In the US, The total annual costs for the 5 major infections were $9.8 billion (95% CI, $8.3‐$11.5 billion), with surgical site infections contributing the most to overall costs (33.7% of the total), followed by ventilator‐associated pneumonia (31.6%), central line‐associated bloodstream infections (18.9%), C difficile infections (15.4%), and catheter‐associated urinary tract infections (<1%).

Zimlichman E et al. Health care‐associated infections: a meta‐analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013 Dec 9‐23;173(22):2039‐46

• In Malaysia: information from Point Prevalence Survey – MOH hospitals

SSI classification

Risk factors/ risk reduction strategies

1. surgical wound class ‐ how dirty or contaminated preoperatively

• means of predicting the likelihood of infection and therefore the need for prophylactic antibiotics

1. Prophylactic antibiotics• Given before or during surgery is to reduce the impact of microbial contamination during surgery and to minimise the risk of infection developing

• Must be aimed at the bacteria most likely to infect the wound and be given at the most appropriate time

• Given before the first incision but no more than 60 minutes before

• If the surgery is longer than 4–5 hours in duration then subsequent doses are recommended

• Subsequent doses of prophylactic antibiotics beyond 24 hours after surgery is not recommended ‐ overuse of antibiotics and the emergence of resistant strains of bacteria

2. Patient factors• Immunosuppressed states‐ chemotherapy, on immunosuppressant drugs, immunosuppressive illnesses

• MRSA colonisation / infection

2a) ScreeningScreening should be undertaken on patients that have previously been known to be MRSA positive, those that have frequent contact with healthcare settings, patients admitted to intensive care units, inpatients undergoing chemotherapy and patients admitted from high‐risk settings such as care homes 

• need to screen those patients that are recognised as being at high risk of being colonised or infected and those that are being admitted for high‐risk procedures

• The most at‐risk groups of patients are those undergoing complex surgery such as cardiac, neuro‐, orthopaedic and vascular surgery and those having surgery to insert an implant 

• the most proactive approach would be that all elective and emergency patients admitted to hospital should be screened for MRSA and isolated until results are known

• Decontamination procedures appear to differ between hospitals, some decontaminate only when the patient is identified as being colonised or infected whereas others start decontamination on admission for those patients deemed to be at high risk

• 3. Type of operation and duration• 4. Lack of asepsis during or after surgery

Prevention of SSI

• 1. Hair removal: shaving not recommended, only clipping

• 2. Normothermia: hypothermia predisposes to SSI by triggering vasoconstriction that reduces subcutaneous oxygen tension and delay wound healing.

• warming blankets, warmed intravenous fluids or raising the operating room’s temperature

• 3. Blood glucose level• Maintained < 11mmol/l, monitored and controlled particularly during 2 days post op to reduce risk of SSI

• Dressing intact primary closed wound for 24-48 hrs

• Aseptic technique for wound care• Pt to report S/S of wound infection• No recommendation for incision closed

beyond 48 hours on dressing change or bath

Post-op incision care

•Surgical attire and drapes

•Asepsis and surgical technique

•Sterilization of surgical instrument

• Environmental factors

Ventilation in OT•Positive-pressure ventilation•15-(25) AC/ hour•At least 3 must be fresh air•HEPA filter•Air in from ceiling & exhaust near floor•Keep doors closed•Ultra-clean air for orthopaedics•Limit number of personnel

CDC Recommendations

Laminar air flow

• Design to move particle-free air (ultra-clean air) with uniform velocity at 0.3 - 0.5 m/sec.

• Vertical is better than horizontal• HEPA filter removes particles >0.3 m • Efficiency of 99.97%• Commonly used in orthopaedic prosthetic

surgery

Steps to Prevent SSI

1. Appropriate use of antibiotics2. Appropriate hair removal3. Post‐operative glucose control (major 

cardiac surgery patients)*4. Post‐operative normothermia (colorectal 

surgery patients)*

* These components of care are supported by clinical trials and experimental evidence in the specified populations; they may prove valuable for other surgical patients as well.

SSI surveillance in Hospital Sungai Buloh

• All types of operations• All surgical disciplines

acara melakukan “surgical sites infection”

1. Menerima senarai pembedahan yang telah dilakukan pada hari sebelumnya

2. Menyenarai pendek setiap pembedahan yang telah dilakukan

3. Merekodkan data kedalam komputer mengikut data yang telah ditetapkan

4. Menyenaraikan nama pesakit yang telah 3 hari menjalani pembedahan

5. Membuat lawatan ke wad

6. Melakukan pemeriksaan keatas luka pesakit

7. Memberi nasihat tentang penjagaan luka

8. Memberikan pamphlet jika pesakit dibenarkan pulang kerumah

9. Melakukan panggilan telefon keatas pesakit dalam masa 30 hari dari tarikh pembedahan

10. Merekodkan kedalam borang “Surgical Sites Infection” jika pesakit didapati mempunyai tanda –

tanda infeksi

11. Melakukan analisa terhadap data yang dikumpulkan pada setiap minggu keempat setiap bulan

12. Merekodkan dan menyediakan statistik mengikut wound class, ASA, jabatan,keseluruhan Hospital

dan durasi pembedahan

13. Menghantar semua statistik kepada setiausaha Kawalan Infeksi Hospital untuk disemak dan

ditandatangani

14. Semua statistik akan dihantar kepada Ketua jabatan pembedahan oleh Setiausaha Kawalan infeksi

melalui email dalaman

15. Melakukan filing

16. Tamat.

Surgical site infection pathway

Descriptive action

Data collectionby OT list

All patients under go operation for elective and emergency surgery from: general surgicalorthopedic, neurosurgery maxillo facialent opthalmologi o&g plastic surgery

-Sorting the OT list for:Included and excluded operation Wound class - clean, clean contaminated,contaminated and dirty

Done by ICN

Operation done Identify any risk factor for SSI

From wound inspection form which done by link nurses and ICN follow up with link nurse in clinic by ICNFrom microbiology lab result –done by ICNmake a call for post operative patient within 30days done by ICN

Analysis Data Submit Statistic before or day 5th

every month to Dr Zubaidah to countercheck and sign

Analysis the data according to :- SSI by Hospital Sungai by wound class -- SSI by department by wound class by surgeonDone by ICN

Name R/n wad sex age DOA DOP OT EL/EM SURGEON PROCEDUREWCL MIN ASA A/B pre op a/b intra op post a/b disease temp humidity DOSSI TYPE sample organismw an hasim 107559 6c f 33 5/1/2013 10/1/2013 4 em dr selvi emlscs c 40min 2e 0 unasyn unasyn POOR PROG 23.2 78 21/1/13 superficialpus sw ab NGnoor salw 238575 6d f 26 23/1/13 23/1/13 3 em dr chuah emlscs c 32miin 2e 0 unasyn 0 hand presentationku ronazie 476536 6c f 24 7/1/2013 7/1/2013 4 em dr ai w ei em lscs c 1h 1 0 unasyn unasyn poor progressnor fadhila 158993 6c f 27 7/1/2013 7/1/2013 4 em dr ai w ei em lscs c 1h 1 0 unasyn unasyn poor progresshasliza ma 475562 6c f 30 7/1/2013 7/1/2013 4 em dr ai w ei em lscs c 1h 1 0 unasyn unasyn fetal distresssiti hasma 105986 6b f 34 19/12/12 28/1/13 4 em dr ai w ei emlscs c 33min 1e 0 unasyn unasyn PP type 2nik zarita 27892 6b f 33 12/1/2013 28/1/13 4 em dr ai w ei emlscs c 45min 1e 0 unasyn unasyn PP in l;abourazlina bt z 479617 6c f 27 27/1/13 29/1/13 4 em dr ai w ei emlscs c 20min 1e 0 unasyn 0 fetal distressnur ain naj 480366 6a f 26 28/1/13 28/1/13 3 em dr ai w ei laparascopic c 1h18m 1e 0 unasyn unasyn ? Cornual prgenancylistina bt ra 477662 6C F 32 9/1/2013 10/1/2013 4 EM DR AI WEI LSCS c 47M 1E 0 unasyn unasyn BREECHsuhaiza 481277 6d f 28 29/1/13 30/1/13 4 el dr akmal ellscs c 1h5min 1 0 unasyn unasyn breech presentationnuramis za 476236 6a f 32 4/1/2013 18/1/13 1 em Dr Akmal em lscs c 48min 1 0 unasyn unasyn fetal distressVIVIAN ON 475690 6C F 24 1/1/2013 2/1/2013 3 EM DR AKMAL EMLSCS C 40 MIN 1E 0 unasyn unasyn FETAL DISTRESSFARIZA S 428536 6D F 28 31/12/2012 2/1/2013 4 EM DR AKMAL EMLSCS C H 15 MIN 1E 0 unasyn unasyn POOR PROGRESSSALINA M 422897 6C F 34 2/1/2013 2/1/2013 4 EM DR AKMAL EMLSCS C 47 MIN 1E 0 unasyn unasyn PREV SCARSUZANA A 313632 6C F 35 8/1/2013 8/1/2013 4 EM DR AKMAL EMLSCS C 57 MIN 2E 0 unasyn unasyn FETAL DISTRESS/GDMRAJA MAZ 478314 6C F 26 14/1/2013 14/1/2013 2 EM DR AKMAL EMLSCS C 56 MIN 1E 0 unasyn unasyn FETAL DISTRESShamidah jir 167913 6c f 39 27/1/13 28/1/13 2 em dr akmal emlscs c 1h 1e 0 unasyn unasyn 2nd arrestshahfarini 269446 6c f 28 27/1/13 28/1/13 4 em dr akmal emlscs c 27min 1e 0 unasyn unasyn fetal distressafnif if il bt b 482220 6b f 29/1/13 29/1/13 4 em Dr Akmal emlscs c 40min 1 0 unasyn 0 face presentationnoramjirah 405772 6c f 42 27/1/13 29/1/13 4 em Dr Akmal emlscs c 40min 1e 0 unasyn 0 fetal distressnorsiah om 207023 6c f 28 10/1/2013 12/1/2013 4 em dr akmal lscs c 40min 2 0 unasyn unasyn fetal distressgayathiry 406409 6c f 29 26/1/13 28/1/13 4 em dr akmal lscs c 1h23m 1e 0 unasyn unasyn poor porgressnor aznida 674450 6c f 30 14/1/2012 15/1/2012 4 el dr akmal hisyellscs c 44min 1e 0 unasyn unasyn breech,gdmlee ying pe 473733 6d f 24 14/1/2013 15/1/2013 4 el dr akmal hisyellscs c 50min 1e 0 unasyn unasyn breechhairiianti m 263159 6d f 36 3/1/2013 3/1/2013 4 em dr akmal hisyemlscs+btl c 52min 2e 0 unasyn unasyn macrosomic baby, 1 prev scar,gdmng soo ma 475596 6c f 35 13/1/2013 15/1/2013 6 em dr akmal hisy lscs c 46min 1e 0 unasyn unasyn fetal distresssuriyati ba 460453 6a f 36 8/1/2013 9/1/2013 3 el dr ambiga se laparotomy, m c 1h 17min 1e 0 unasyn unasyn large fundal fibroidERNAWAT 383714 6C F 24 8/1/2013 8/1/2013 4 EM DR AZLEEN EMLSCS C 20 MIN 1E 0 unasyn unasyn POOR PROGRESSnurul liza 363405 6c f 32 13/1/2013 13/1/2013 4 em dr bahiah em lscs c 1h 1 0 unasyn unasyn fetal distresssiti hajar k 429934 6b f 28 13/1/2013 13/1/2013 3 em dr bahiah em lscs c 1h 1 0 unasyn unasyn fetal bradycardiadinne napa 460302 6c f 31 13/1/2013 13/1/2013 4 em dr bahiah em lscs c 1h 1 0 unasyn unasyn fetal distresssuyyideh 478241 6c f 40 11/1/2013 11/1/2013 1 em dr bahiyah emlscs c 34min 2e 0 unasyn 0 placenta previaliew xue m 136078 6a f 23 12/1/2013 12/1/2013 2 em dr bahiyah lap diagnostic c 1h30min 2 0 unasyn unasyn uterine perforationsriw ahyun 470100 6a f 36 22/1/13 23/1/13 3 el dr chong (L) salphingo c 1h 15min 1 0 unasyn 0 ovaraian tumorSITI ANA 185390 6C F 35 26/1/2013 26/1/2013 4 EM DR CHONG EMLSCS C 39 MIN 1E 0 unasyn unasyn TWIN LABOURhasliza ab 481162 6a f 32 24/1/13 24/1/2013 4 em dr chong hysterostomy c 57min 1 0 unasyn unasyn abrutio placentaNursyahid 461132 6a f 25 22/1/13 23/1/13 3 el dr chong laparoscopic c 3h 22min 1 0 unasyn 0 (L) ovarian cystnor asikin 459200 6a f 25 25/1/2013 25/1/2013 3 el dr chong laparotomy a c 2h 1 0 unasyn unasyn Huge ovarian cystsiti ajal yas 449871 6a f 45 25/1/2013 25/1/2013 3 el dr chong TAHBSO c 3h 1 0 unasyn unasyn multiple utrine f ibroidsuzzuliana 458242 6a f 20 22/1/13 23/1/13 3 el dr chong laparotomy c c 41min 1 0 unasyn 0 ovarian cyst nor hidaya 475582 6b f 23 1/1/2013 1/1/2013 4 em dr chopra em lscs c 1h 1 0 unasyn unasyn severe peDarw ani A 477742 6b f 29 9/1/2013 9/1/2013 4 em dr chopra hyesterectom c 3h 50min 1 0 unasyn 0 pph 22.8 76 15/1/13 deep tissue NGanida hani 427067 6a f 42 15/1/13 16/1/2013 3 el dr chopra laparatomym c 1h30m 2e 0 unasyn unasyn large uterine f ibroid, co DMHypercholestrolcemia, thalessiamia

FORMAT BORANG SSI

• NAMA• R/N• WAD/BED• SEX• AGE

cont…

• UNDERLYING DISEASE• OT ROOM• OT TYPE: EM/EL• TYPE OF OPERATION• WCL• SURGEON /OT TEAM• ASA• DOP 

cont..

• ANTIBIOTIK PROPHYLAXSIS 

• PRE OP/ INTRA OP/ POST OP 

WOUND BREAKDOWN DI WAD

1. Menerima pangilan telephone daripada link nurse di wad

2. Membuat lawatan ke Wad

3. Mengenalpasti bagaimana SSI terjadi dengan merekodkan keterangan penjagaan luka semasa

dirumah atau apa – apa yang berkaitan

4. Membuat lawatan setiap 3 hari sehingga pesakit discaj dari wad.

SAMPLE PESAKIT YANG POSITIF

1. Menerima Sample swab atau tisu kultur positive dari makmal

2. Menyemak rekod pesakit samada pesakit ada menjalani pembedahan atau tidak

3. Jika Sample kultur adalah dari pesakit pembedahan semak rekod tarikh sample diambil untuk

menentukan SSI

4. Jika terdapat “surgical site infection” rekod kedalam buku “SSI” yang telah di sediakan

5. Membuat lawatan ke wad untuk mengetahui tahap”SSI

BIL Nama R/N Wad Sex Umur Date op OT OT Typ Surgeon Procedure WCL Duration1 NGAH SEMIAH BINTI SO216076 5B F 62 24/112/09 2 EL MR SHUKRI/MR S(L) MASTECTOMY CLEAN H 56MIN 2 HJ YUSUF@KAMARUDIN179997 5C M 29/12/09 3 EM MR SHANKAR/DRAPPENDICECTOM DIRTY H 44MIN 3 RAJES SPERY A/P GENG71808 5B F 50 22/12/09 2 EM MR SHANKAR/DRLAPAROTOMY CO 2H 15 MIN 4 AZRI IZZUDDIN B. AWAL228769 5C M 16 27/12/09 1 EM DR NORSHAZATUAPPENDICEC DIRTY 1H 30MIN 5 MOHD YUSOP B. AMIS 228530 4B M 64 24/12/09 2 EM MR SHUKRI/MR SLAPAROTOMY DIRTY 5H6 SITI FATEHAH BTE MOH224168 5B F 20 1/12/2009 2 EM MR PEH/DR VICK APPENDICEC DIRTY 3H 50 MIN

CL CC CO DKES 20 14 30 16SSI 1 0 1 4% 5.0% 0.0% 3.3% 25.0% 7.50%

6

SENARAI NAMA PESAKIT YANG MENGALAMI SSI JABATAN SURGIKAL BULAN JAN 2010

SSI MENGIKUT WOUND CLASS JAN 2010TO TAL KES

80

5.0%

0.0%

3.3%

25.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

CL CC CO D

PERCENTAGE OF SSI BY WOUND CLASS JANUARY 2010 GENERAL SURGERY DEPARTMENT

PERCENTAGE SSI

KOD TOTAL KESSI %S1 27 2 7.40%S2 13 4 30.70%S3 14 1 7.14%S4 0 0 0.00%S5 5 1 20.00%S6 6 0 0.00%S7 6 0 0.00%S8 16 1 6.25%S9 7 3 42.80%S10 6 1 16.60%S11 8 0 0.00%S12 5 1 20.00%

SURGIKAL SITES INFECTION BY SURGEON JABATAN SURGERY BULAN JAN 2010

PERCENTAGE OF SSI BY SURGEON JANUARY 2010 GENERAL SURGICAL DEPARTMENT

7.40%

30.70%

7.14%

0.00%

20.00%

0.00% 0.00%

6.25%

42.80%

16.60%

0.00%

20.00%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

S1 S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12

%

SSI BY WOUND CLASS

CL CC CO D

SSI 1 0 1 4

% 16.7% 0.0% 16.6% 66.6%

SSI by duration

more than 3H less than 3H

ssi 2 4

% ### 66.60

SSI BY ASA ASA 1 0ASA MORE THAN 1 6

SSI by ASA (Orthopedic Jan 2010)

0

1

2

3

4

5

6

7

ASA 1 ASA MORE THAN 1

Series1

Thank You