CDC balks at endorsing surgeon-specific SSI rates
ICPs decide scope of outpatient, discharge tracking
Though some studies report that collecting and reporting surgeon-specific infection rates reduces surgical site infections (SSIs), the Centers for Disease Control and Prevention found insufficient justification to endorse the controversial practice in its recently finalized SSI guidelines.1
One recent study attributed considerable cost savings and a 49% reduction of SSIs to surgeon-specific reporting, though even advocates of the practice concede it is not completely understood how the feedback lowers subsequent rates.2 (See Hospital Infection Control, July 1999, p. 93.) Such suggestions of efficacy are not compelling enough to specifically endorse the practice, which could unfairly reflect on surgeons who operate on patients at higher risk for infection, notes Alicia Mangram, MD, lead author of the guidelines while at the CDC hospital infections program and now in surgical residency at the University of Texas in Houston.
"The studies support that [rates decline] because it makes the surgeon more aware of what is going on in his or her particular practice," she says. "But nobody has [followed] 20 different surgeons, actually looked at their data, and saw that their infection rate was substantially decreased in a statistical fashion using a good prospective controlled study."
Unless all risk variables are accounted for, the practice could simply ascribe a higher infection rate to surgeons who operate on the sickest patients, possibly engendering a reluctance to take such cases among clinicians who know their rates are being collected and compared, she notes. "Does this surgeon really have a higher infection rate, or is [he] operating on patients that are about to die and he is the only one brave enough to take on the challenge?" Mangram asks. "That’s the problem. Because there are surgeons we know who will take the really severely ill patients, and they might be the ones that have the high infection rates. It’s an unresolved issue, because it won’t be looked at fairly."
Nevertheless, the SSI prevention guidelines issued by the CDC Healthcare Infection Control Practices Advisory Committee do not specifically prohibit the practice. (See rankings, above; guidelines, pp. 105-106.)
"It doesn’t rule it out and doesn’t necessarily say that it most be done," says Ona Baker, RN, infection control coordinator at the VA Medical Center in Amarillo, TX. "If it was important but the data wasn’t strong, they could have recommended giving surgeon-specific feedback but made it a Category II’ [ranking], which would mean you have to take it with a grain of salt. I kind of expected that, based on the preponderance of anecdotal reports."
While not endorsing surgeon-specific rates, the CDC recommends that ICPs periodically calculate "operation-specific" SSI rates stratified by risk factors. "We are talking about the rate [for example] of all of the appendectomies performed in the hospital," Mangram says. "Now, of course, most infection control practitioners will break that down into surgeon-specific infection rates, but we’re not sure that is data that needs to be distributed. That can be sort of risky business."
Surgeon-specific reporting: Unresolved issue’
Indeed, the guidelines assign the ranking of "no recommendation/unresolved issue" to the practice of reporting coded surgeon-specific data to infection control committees. While the recommendation would presumably apply to other committees as well, a direct statement discouraging infection rate disclosures to committees like performance improvement or recredentialing panels might have been helpful to ICPs pressured to disclose such data, adds Baker.
"That’s what really causes a conundrum with infection control people and their surveillance data," says Baker, who often speaks on surveillance and outcomes issues at educational conferences. "Not reporting it to the infection control committee in a coded way would not tend to be a big political problem like not passing it on to other committees."
The CDC guidelines also address the tremendous shift to outpatient surgery, noting that an estimated 75% of all operations in the United States will be performed in outpatient settings by the year 2000. While it may be appropriate to use common definitions of SSIs for inpatients and outpatients, the types of operations monitored, the risk factors assessed, and the case-finding methods used may differ.
"At some point in time, I’m sure we’re going to have data comparing ambulatory-setting surgical site infections with inpatient-setting SSIs," Mangram says. "There is going to be a statistical difference between the two, because the patients who have ambulatory care surgical procedures performed have decreased risk."
Though many outpatient infections are likely to be relatively minor, it is still important to track ambulatory procedures, Mangram adds. "Despite our own intuition telling us that the number of SSIs in the outpatient population is going to be substantially smaller, we could be wrong. What we may find is that there are no deep organ/space surgical site infections, but the number of superficial site infections may not be any different [than inpatient] and they may be something we need to know. So I think it will be important."
How can outpatients be tracked?
But surveillance for such procedures is difficult, she says, noting that it is hard enough to keep track of hospitalized patients post-discharge. "The chances that [outpatients] will even go back to the surgeon other than to have their sutures removed are minimal," she says. "They will go to their primary care physician. So I think surveillance in the ambulatory care setting is going to be difficult." Possible surveillance methods for ambulatory procedures include pharmacy approaches that track patients who receive antibiotics postoperatively, and microbiological systems that red-flag patients who have cultures sent in for testing, she adds.
"You probably wouldn’t devote the same resources, but my impression from a lot of experts is that it would be a mistake to totally eliminate that [outpatient] element of the surveillance," Baker says. "You just miss too big of the proportion of [procedures] and the opportunity to look at performance. Even if they are at perhaps lower risk for severe outcome, any one of them has the potential to result in a severe outcome."
Baker also reminds that surveillance for outpatient procedures should not be confused with post-discharge surveillance for surgical inpatients. "These are hospitalized patients who had their procedures inpatient," she says. "You still need to follow those, [because] those very well could be fairly high-risk procedures like cardiovascular and major orthopedic procedures that tend to present late with infections. You can’t lump post-discharge surveillance in with ambulatory surgery surveillance in terms of how you do your resource assignments."
A variety of surveillance approaches is being tried to capture post-discharge infections, but as with outpatient SSIs, the CDC concluded there is no consensus approach to recommend. The final guidelines for SSI prevention essentially advise infection control professionals to weigh their local situation and available resources in adopting the most feasible and effective method to track post-discharge and outpatient infections. Regardless of the approach taken, the CDC recommended using its definitions for SSIs without modification in both inpatient and outpatient settings. As integrated health information systems expand, tracking surgical patients through the course of their care may become more feasible, practical, and effective, the CDC states.
References
1. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999; 20:257-280.
2. Smyth E, Barr J, Webb C, et al. Potential savings achieved due to a reduction in surgical site infections over a twenty-four month period. Abstract 58. Presented at the annual conference of the Society for Healthcare Epidemiology of America. San Francisco; April 18-20, 1999. n
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