CDC: No consensus exists for SSI tracking methods
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 (CDC) in Atlanta.
Thus, draft SSI prevention guidelines by the CDC essentially advise professionals to weigh their local situations and available resources in adopting the most feasible and effective method to track post-discharge and outpatient infections.1 Regardless of the approach taken, the CDC recommends using its definitions for SSIs without modification in both inpatient and outpatient settings. (See definitions, p. 130.)
In the draft, the CDC notes 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. Since the length of postoperative hospitalization continues to decrease, true estimates of SSI risk will be possible only by performing a combination of inpatient and post- discharge surveillance, the draft states.
Post-discharge surveillance methods that have been used with varying degrees of success include direct examination of wounds during follow-up visits to surgery centers or physicians; review of medical records of surgery center patients; and administration of questionnaires to patients or physicians by mail or phone. One study found that patients have difficulty assessing their own wounds for infection, which suggests data from patient questionnaires may inaccurately represent SSI rates, the CDC reports.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 draft states. "Until then, there is no consensus on which post- discharge 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 post-operative clinic visit to identify SSIs.4 While ascertainment was high, essentially 100%, this method is impractical for widespread imple mentation, the draft states. In general:
· high response rates have been obtained from questionnaires mailed to surgeons;
· response rates from telephone questionnaires administered to patients were more variable;
· response rates from questionnaires mailed to patients were quite low.
"At this time, no single detection method can be recommended," the CDC concludes. "[Use] available resources and data needs [to] determine which methods should be used and which operations should be monitored."
SSI surveillance recommendations
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 the Hospital Infec tion Control Practices Advisory Committee (HICPAC), based on a 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.
o Use CDC definitions of SSI without modification for identifying SSI among surgical inpatients and outpatients. (Category IB)
o For inpatient case-finding, use direct prospective 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 post-discharge surveillance that accommodates available resources and data needs. (Category IB)
o For outpatient case-finding, use a method that accommodates available resources and data needs. (Category IB)
o 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)
o Upon completion of the operation, a surgical team member assigns the surgical wound classification. (Category IB)
o Periodically calculate operation-specific SSI rates stratified by variables shown to be predictive of SSI risk. (Category IB)
o 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)
o There is 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 167-33, 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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