How can outpatients be tracked for infection?
CDC releases new SSI guidelines
In releasing recent guidelines on surgical site infections (SSIs), the Centers for Disease Control and Prevention (CDC) emphasizes the importance of tracking infections for outpatient surgery patients, acknowledges the particular challenges of tracking such patients, but stops short of recommending a consensus approach on how to do it.
The CDC guidelines address the compelling shift to outpatient surgery and note 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 SSI 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," says Alicia Mangram, MD, lead author of the guidelines written while at the CDC hospital infections program and now in surgical residency at the University of Texas in Houston. "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 be relatively minor, it is still important to track ambulatory procedures, Mangram adds. "Despite that our own intuition tells 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 that may be something we need to know. So I think it will be important."
But surveillance for such procedures is difficult, she says, and notes that it is difficult 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."
Same-day surgery managers have used questionnaires to patients and surgeons with little success, says Teresa Horan, MPH, CIC, epidemiologist at the CDC. "You may get a good response rate, but that doesn’t necessarily mean good surveillance data," she says. "I talk to a lot of people who say, We have 90% of surgeons responding to our questionnaire about their patients.’ But that doesn’t mean they’re finding 90% of infections."
Surgeons aren’t always the best at identifying or reporting infections, Horan says. "Patients aren’t that good either," she says. "So while we might be able to reach them, what we’re looking for is more objective ways to get information.
For example, if a patient picks up an antibiotic or returns to a clinic, that might be a sign of an SSI, she says. "We have a study going on looking at integrated health care systems to determine if there’s other ways to access existing databases in a managed care environment to see if we can identify [patients who get] SSIs after they leave inpatient or outpatient surgery."
While a variety of surveillance approaches are being tried to capture post-discharge infections, the CDC concluded there is no consensus approach to recommend. The final guidelines for SSI prevention essentially advise providers to weigh their local situation and available resources in adopting the most feasible and effective method to track post-discharge 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.
Though some studies state that collecting and reporting surgeon-specific infection rates reduce SSIs, the CDC found the data insufficient to endorse the controversial practice in its recently finalized SSI guidelines.1
One recent study attributed major cost savings and a 49% reduction of SSIs to surgeon-specific reporting, though advocates of the practice concede it is not completely understood how the feedback lowers subsequent rates.2 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, Mangram notes.
Nevertheless, the SSI prevention guidelines issued by the CDC Healthcare Infection Control Practices Advisory Committee do not specifically prohibit the practice. (See rankings, above, and an excerpt of the guidelines, inserted in this issue.)
However, the CDC recommends that providers 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.
(Editor’s note: Readers can access the full SSI guidelines on the CDC Web site: www.cdc.gov/nci dod/hip. Readers can receive free CME or CE contact hours on-line.)
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 Society for Healthcare Epidemiology of America (SHEA). San Francisco; April 18-20, 1999.
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