SSI tracking unresolved for some outpatients
October 1, 1998 4 minutes read
SSI tracking unresolved for some outpatients
ICPs must weigh options and local resources
A variety of surveillance approaches are being attempted to capture post-discharge and outpatient surgical site infections (SSIs), but there is no consensus approach to recommend for either area, reports the Centers for Disease Control and Prevention.
Thus, draft SSI prevention guidelines by the CDC essentially advise infection control professionals to weigh their local situations and available resources in adopting the most feasible and effective methods to track postdischarge and outpatient infections.1 Regardless of the approach taken, the CDC recommended using its definitions for SSIs without modification in both inpatient and outpatient settings. (See definitions, p. 153.)
The CDC notes in the draft that between 12% and 84% of SSIs are detected after patients are discharged from the hospital, with some studies suggesting SSIs become evident within 21 days after the operation. Because the length of postoperative hospitalization continues to decrease, true estimates of SSI risk will only be possible by performing a combination of inpatient and postdischarge surveillance, the draft states.
Postdischarge surveillance methods that have been used with varying degrees of success include direct examination of patients' wounds during follow-up visits to either surgery clinics or physicians. Other approaches include review of medical records of surgery clinic patients and administering questionnaires either to patients or physicians by mail or telephone. One study found that patients have difficulty assessing their own wounds for infection, suggesting that data obtained by patient questionnaire may inaccurately represent actual SSI rates, the CDC reported.2 Another study found that medical databases may be useful surveillance tools, particularly pharmacy records indicating a patient had received antimicrobial agents commonly used to treat soft-tissue infections.3
"As integrated health information systems expand, tracking surgical patients through the course of their care may become more feasible, practical, and effective," the CDC draft says. "Until then, there is no consensus on which postdischarge surveillance methods are the most sensitive, specific, and practical. Infection control and surgery personnel must choose from a variety of methods to find those that work for their unique mix of operations, personnel resources, and data needs."
In a similar vein, the CDC notes that both direct and indirect methods have been used to detect SSIs that complicate outpatient operations. One study used home visits by district health nurses combined with a questionnaire completed by the surgeon at the patient's two-week postoperative clinic visit to identify SSIs.4 While ascertainment was very high, essentially 100%, this method is impractical for widespread implementation, the draft states. In general, response rates from questionnaires mailed to surgeons were high; response rates from telephone questionnaires administered to patients were more variable; and response rates from questionnaires mailed to patients were quite low.
"At this time, no single detection method can be recommended," the CDC concluded. "[Use] available resources and data needs [to] determine which methods should be used and which operations should be monitored."
The CDC recommendations for SSI surveillance are summarized below and ranked according to the following system:
Category IA - Strongly recommended for all hospitals and strongly supported by well-designed experimental or epidemiological studies.
Category IB - Strongly recommended for all hospitals and viewed as effective by experts in the field and a consensus of Hospital Infection Control Practices Advisory Committee members, based on strong rationale and suggestive evidence, even though definitive scientific studies may not have been done.
Category II - Suggested for implementation in many hospitals. Recommendations may be supported by suggestive clinical or epidemiological studies, a strong theoretical rationale, or definitive studies applicable to some (but not all) hospitals.
No recommendation; unresolved issue - Practices for which insufficient evidence or no consensus regarding efficacy exists.
Surveillance Recommendations
· Use CDC definitions of SSI without modification for identifying SSI among surgical inpatients and outpatients. (Category IB)
· For inpatient case-finding, use direct pro spective observation, indirect prospective detection, or a combination of both direct and indirect methods for the duration of the patient's hospitalization, and include a method of postdischarge surveillance that accommodates available resources and data needs. (Category IB)
· For outpatient case-finding, use a method that accommodates available resources and data needs. (Category IB)
· For each patient undergoing an operation chosen for surveillance, record those variables shown to be associated with increased SSI risk (e.g., surgical wound class, ASA class, and duration of operation). (Category IB)
· Upon completion of the operation, a surgical team member assigns the surgical wound classification. (Category IB)
· Periodically calculate operation-specific SSI rates stratified by variables shown to be predictive of SSI risk. (Category IB)
· Report appropriately stratified, operation-specific SSI rates to surgical team members. The optimum frequency and format for such rate computations will be determined by stratified caseload sizes and the objectives of local continuous quality improvement initiatives. (Category IB)
· No recommendation to make available to the infection control committee coded surgeon-specific data. (Unresolved issue)
References
1. Centers for Disease Control and Prevention. Draft guideline for prevention of surgical site infections, 1998. 63 Fed Reg 167-133, 192 (June 17, 1998).
2. Seaman M, Lammers R. Inability of patients to self-diagnose wound infections. J Emerg Med 1991; 9:215-219.
3. Sands K, Vineyard G, Platt R. Surgical site infections occurring after hospital discharge. J Infect Dis 1996; 173: 963-970.
4. Goulbourne IA, Ruckly CV. Operations for hernia and varicose veins in a day-bed unit. Br Med J 1979; 2:712-714.
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