Using the COLO and HYST Surgical Site Infection (SSI) Medical Record Abstraction Tools Janet Brooks RN, BSN, CIC Nurse Consultant State HAI Grantee Meeting November 14, 2013 National Center for Emerging and Zoonotic Infectious Diseases Place Descriptor Here
COLO and HYST Medical Record Sampling
Targeted Medical Record Sampling How can we find medical records with high likelihood of HAI or surveillance error (targeting)? For SSI, use estimated risk ( modelriskall ) from NHSN Other effective options more difficult and not available to all states / facilities, e.g: Link to high-risk ICD-9-CM codes (as done in NYS, and by CMS) Link to pharmacy data (antibiotic use)
ModelRiskAll Score Automatically generated in NHSN as procedure is entered ModelRiskAll Score Uses univariate risk factors: (COLO) anesthesia, endoscope, gender, ASA score, wound class, bed size, age, duration (HYST) anesthesia, endoscope, ASA score, wound class, duration
Procedure Selection Step-by-Step guidance in Appendix 2, Part 4 Use procedures reported to NHSN Identify those with reported SSI Choose 20 COLO / 20 HYST (random sample if more than 20) Choose 40 more COLO / 40 more HYST procedures: Select those targeted with the highest ModelRiskAll Scores
Request to Facility Part 1: Numerator and risk-adjustment variable audit: After selecting procedures in NHSN: Freeze (download) the facility NHSN data Request medical records for audit Part 2: Denominator Audit Request
How Can You Know if NHSN Denominator is Complete? Request NHSN Procedure Counts by Month Provide NHSN ICD-9-CM procedure codes to the facility Ask them to enumerate procedures performed each month according to Medical Records This should correlate pretty well with the number of procedures entered into NHSN
SSI Validation Goals/Objectives Using a medical record targeted for SSI review, validate NHSN procedure (denominator), riskadjustment variables, and evaluate for SSI (numerator) within 30 days post procedure Please use the MRAT Processes Standardize validation with embedded support Document criteria and decisions during the medical record review process Benefit from available companion tools TN healthcare-associated infection (HAI) checklists Create record of validation findings Available if adjudication is required
Using the COLO and HYST Surgical Site Infection (SSI) Medical Record Abstraction Tools Janet Brooks RN, BSN, CIC Nurse Consultant State HAI Grantee Meeting November 14, 2013 National Center for Emerging and Zoonotic Infectious Diseases Place Descriptor Here
COLO MRAT Overview (Page 1 - section 1 and 2) Abstract Identifiers Describe surgical procedure(s) Record ModelRiskAll Score from NHSN Identify readmissions during 30-days post procedure
Identifiers 9999 State, Facility, Date of audit Patient ID: if possible, ask IP what they use for NHSN reporting (you will only need this to identify reported cases), or use MRN orgid and patient DOB may be needed for NHSN matching if MRN is not used for reporting Document review start and end times
KEA2 Characterize Surgical Procedure(s) 9999 COLO procedure date Qualifying NHSN COLO ICD-9 code Describe all procedures performed at time of COLO (e.g. Exploratory lap, appendectomy)
Slide 12 KEA2 should these be deleted? Kathryn E. Arnold, 9/19/2013
COLO ICD-9-CM Codes (Do not use CPT codes) When an NHSN Operative Procedure is selected for monitoring, all the procedures within that category must be followed. ICD-9-CM Codes CPT Codes Each NHSN operative procedure category is defined by a group of ICD-9-CM procedure codes
Record ModelRiskAll Score from NHSN 9999 The ModelRiskAll score (along with two other risk scores) is automatically generated by NHSN when procedures are entered. It is based on univariate risk models.
Identify readmissions during 30-days post procedure surveillance period 9999 Any readmissions during the 30-day surveillance window should be reviewed for SSIs, in addition to the index admission
Key Term: NHSN Operative Procedure A procedure that 1. is performed on a patient who is an NHSN inpatient or an NHSN outpatient, 2. takes place during an operation where a surgeon makes a skin or mucous membrane incision (including the laparoscopic approach) and primarily closes the incision before the patient leaves the operating room, and 3. is represented by an NHSN Operative Procedure Code.
Assure NHSN Procedure Criteria 9999 Note: Clarification of primary closure definition as of 4/1/13
Primary Closure Primary closure is defined as closure of all tissue levels during the original surgery, regardless of the presence of wires, wicks, drains, or other devices or objects extruding through the incision. This category includes surgeries where the skin is closed by some means, including incisions that are described as being loosely closed at the skin level. Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery.
Document riskadjustment variables Document later surgery during surveillance window Post-discharge surveillance information Evaluate for SSI Attribution of SSI to Procedure COLO MRAT Overview (Page 2 - sections 3-7)
Document Risk-adjustment Variables 9999 Risk adjustment variables are in the NHSN database, these can be abstracted and verified, in addition to validating the SSI outcome. This is optional data to be collected, if you wish to validate it (preferred).
Document Additional Surgery During 30-day Surveillance Window 9999 After the initial 24-hours, any additional surgery that reopens the incision during the 30-day surveillance period will stop the clock This closes the surveillance window for the original surgery, because any SSI that follows will be attributed to the additional surgery and not to the index procedure
Post-Discharge Surveillance Information This section reminds the validator to look for additional records (such as clinic notes, ED visits, patient or physician surveys) that might document surgical outcome.
Evaluate for SSI Criteria section 6 SSI criteria are in vertical columns on page 4 This table can function as a checklist Evaluate for all three levels: superficial, deep incisional, and organ/space during surveillance window (up to 30 days) Record result on MRAT page 3
SSI Criteria Can function as a checklist 9999
SSI Definitions Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13(10):606-8.
Only for DI and O/S SSI
Superficial Incisional SSI Infection occurs within 30 days after any NHSN operative procedure, including those coded as OTH and involves only skin and subcutaneous tissues of the incision and patient has at least one of the following: a. purulent drainage from the superficial incision b. organisms isolated from an aseptically-obtained culture of fluid or tissue from the superficial incision c. superficial incision that is deliberately opened by a surgeon and is culture-positive or not cultured and patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; redness; or heat. A culture-negative finding does not meet this criterion. d. diagnosis of a superficial incisional SSI by a surgeon or attending physician.
Reporting Instruction The term attending physician for the purposes of application of the NHSN SSI criteria may be interpreted to mean the surgeon(s), infectious disease, other physician on the case, emergency physician or physician s designee (nurse practitioner or physician s assistant).
Reporting Instructions Do not report a stitch abscess (minimal inflammation and discharge confined to the points of suture penetration) as an infection. Do not report a localized stab wound or pin site infection as SSI. While it would be considered either a skin (SKIN) or soft tissue (ST) infection, depending on its depth, it is not reportable under this module. Diagnosis of cellulitis, by itself, does not meet criterion d for superficial incisional SSI.
Deep Incisional SSI Infection occurs within 30 or 90 days after the NHSN operative procedure according to the list in Table 3 and involves deep soft tissues of the incision (e.g., fascial and muscle layers) and patient has at least one of the following: a. purulent drainage from the deep incision b. a deep incision that spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured and patient has at least one of the following signs or symptoms: fever (>38 C); localized pain or tenderness. A culture-negative finding does not meet this criterion. c. an abscess or other evidence of infection involving the deep incision is found on direct examination, during an invasive procedure, or by histopathologic examination or imaging test d. diagnosis of a deep incisional SSI by a surgeon or attending physician.
Reporting Instructions Classify infection that involves both superficial and deep incisional sites as deep incisional SSI. Classify infection that involves superficial incisional, deep incisional, and organ/space sites as deep incisional SSI. This is considered a complication of the incision.
Organ/Space SSI Infection occurs within 30 or 90 days after the NHSN operative procedure according to the list in Table 3 and involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and patient has at least one of the following: and a. purulent drainage from a drain that is placed into the organ/space b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space c. an abscess or other evidence of infection involving the organ/space that is found on direct examination, invasive procedure, or by histopathologic examination or imaging test d. diagnosis of an organ/space SSI by a surgeon or attending physician. meets at least one criterion of a specific organ/space infection site listed in Table 4.
Reporting Instructions If a patient has an infection in the organ/space being operated on and the surgical incision was closed primarily, subsequent continuation of this infection type during the remainder of the surveillance period is considered an organ/space SSI, if organ/space SSI and site-specific infection criteria are met. Rationale: Risk of continuing or new infection is considered to be minimal when a surgeon elects to close a wound primarily. Occasionally an organ/space infection drains through the incision and is considered a complication of the incision. Therefore, classify it as a deep incisional SSI. Present on admission (POA) does not apply in the reporting of SSIs.
SSI after Laparoscopic Procedure If more than one of the laparoscopic/robotic incisions becomes infected, report only one SSI If one is a superficial incisional SSI and another is a deep incisional SSI, report as a deep incisional SSI
If you identify an SSI: Attribution of SSI - Section 7 Date of event (date LAST required element was met) Must be within surveillance window Evaluate attribution of SSI to COLO vs. another NHSN procedure
Attribution of SSI - Section 7 Hierarchy of Abdominal Procedures: Use only if cannot determine which eligible procedure is the source of the SSI
Record the outcome COLO MRAT Overview (Page 3 - section 8) Don t forget to record review end time
Tips MRAT presents questions in the order needed to derive the correct outcome (supporting NHSN definitions) Similar to standardized approach used by CMS MRAT provides reminders and written documentation of criteria, in case of discordant outcomes Likely to get easier and faster with experience Validation focus is on primarily on outcomes (SSI yes or no, and type/depth of SSI) Can also look for discordant procedures, risk adjustment variables.
HYST Process Very Similar to COLO Abstract Identifiers Describe surgical procedure(s) Record ModelRiskAll Score from NHSN Identify readmissions during 30-days post procedure
Characterize Surgical Procedure(s) 9999 HYST procedure date, Qualifying HYST ICD-9 code Describe all procedures done with HYST ModelRiskAll Score Readmissions during the 30-day surveillance window
HYST Operative Procedure Codes Each NHSN operative procedure category is defined by a group of ICD-9-CM procedure codes ICD-9-CM codes CPT-codes ->
Definition of a HYST Procedure The ICD-9-CM procedure code should be used to determine if the case is a HYST. HYST can be done with an open incision or via multiple laparoscopic sites.
Important HYST Reporting Detail The assigned ICD-9-CM code is determined by the structures removed and how they were detached (the surgical technique or approach), and not the route by which the structures were physically removed; NHSN guidance now reflects this 68.41 Laparoscopic total abdominal hysterectomy (HYST), even if uterus is removed through the vagina 68.51 Laparoscopically assisted vaginal hysterectomy (VHYS); vaginal incision
Assure Case Meets NHSN Procedure Criteria 9999
Document riskadjustment variables (optional) Document later surgery during surveillance window Post-discharge surveillance information Evaluate for SSI Attribution of SSI to HYST or other NHSN procedure HYST MRAT Overview (Page 2 - sections 3-7)
HYST MRAT Overview (Page 3 - section 8)
Questions?
Case Studies Using COLO and HYST Surgical Site Infection (SSI) Medical Record Abstraction Tools National Center for Emerging and Zoonotic Infectious Diseases Place Descriptor Here
Case 1 HYST MRAT A 61 y.o. female is admitted to the hospital on 04/12/13 for elective surgery and MRSA active screening test is positive. On the same day, patient undergoes total abdominal hysterectomy (HYST: ICD-9 Code 68.39). Incision closed at end of case with one JP drain placed in the incision. Postoperative course is unremarkable; patient discharged on 4/15/13. On 4/29/13, patient is readmitted with complaints of acute incisional pain for past 2 days. Surgeon removed 5 staples and opened the wound into the fascial level. Specimen sent of drainage found in the deep fascial layer. Wound packed. Antibiotics ordered. On 5/1, culture results are positive for MRSA. Patient discharged on 5/3/13. Discharge summary states Surgical site infection.
Case one MRAT page 1 GA 12345 JB 10/01/13 01/14/52 F111111 F 1010 04 12 04/12/13 04/15/13 No additional procedures 0.0032 04 29 13 05 03 13
Procedure Criteria Page 1 - Section 2
Risk Adjustment Variables Page 2 Section 3 61 04/12/13 0830 04/12/13 0945 1 15
Subsequent surgeries and Post-discharge surveillance Page 2 Sections 4 and 5
SSI Definition Criteria Page 2 - Section 6
MRAT SSI Criteria section 6 leads to part 9
SSI criteria case 1
SSI criteria case 1
Section 8 Audit Outcome 04/29/13
Attribution of SSI - Section 7
Case 2 COLO MRAT 70 y. o. male patient admitted on 3/10/13 and underwent a hemi-colectomy (ICD 9 Code 17.39) and repair of an abdominal wall hernia (ICD 9 Code 53.59) via the same incision on day of admission. The incision was closed and a JP drain was placed via a stab wound in the LLQ. Patient discharged on 3/14/13. 3/17/13 patient arrives to ED with a red, painful incision and the incision is draining yellow foul smelling discharge from the superficial incision. Physician removes 2 staples and probes wound. The fascia is intact and only the subcutaneous tissue is involved. No cultures were obtained. Antibiotics ordered, wound packed and patient discharged home.
Case 2 MRAT page 1 GA 015363 JB M333333 03/10/13 M 03/14/13 03 10 Abdominal wall hernia repair 0.0281
Procedure Criteria Page 1 - Section 2
Subsequent surgeries and Post-discharge surveillance Page 2 Sections 4 and 5
SSI Definition Criteria Page 2 - Section 6
MRAT SSI Criteria section 9
SSI criteria case 2
SSI criteria case 2
Section 8 Audit Outcome 03/17/13
Attribution of SSI - Section 7 Were additional NHSN procedures performed during the index COLO surgery or within 24 hours through the same incision site, and if so, was the SSI attributable to this other procedure?
Attribution of SSI - Section 7 Section 7 is the reminder to check if additional NHSN procedures were performed during the index COLO surgery or within 24 hours through the same incision site, and if so, was the SSI attributable to this other procedure?
Case 3 COLO MRAT 5/15/13: A 60 year-old female admitted with an acute abdomen. Patient sent to OR and finding was a ruptured diverticulum with fecal contamination of the abdominal cavity (wound class 4). A colectomy is performed and a colostomy is formed. Incision is loosely closed with staples to allow for drainage. Antibiotics ordered. 5/19/13: Patient progressing well; afebrile; with decreasing abdominal pain; discharged home 5/25/13: Patient presents to ED with fever of 38.5 C; abdominal pain; CT scan suspicious for large abscess; Patient admitted 5/26/13: To OR and for I&D of wound and drainage of large intraabdominal abscess. Specimen obtained; Wound left open and wound vac placed; Antibiotics ordered 5/27/13: Culture of abscess (+) for B. fragillis 5/30/13: Discharged home on 5/30.
Case 3 MRAT page 1 GA 015363 JB F55555 05/15/13 F 05/19/13 05 15 No other procedures performed 0.0281 05 25 13 05 30 13
Procedure Criteria Page 1 - Section 2 Note: Wound class of 4 does not exclude a COLO from being entered into the denominator data
Subsequent surgeries and Post-discharge surveillance Page 2 Sections 4 and 5 05/15/13 05/26/13
SSI Definition Criteria Page 2 - Section 6
MRAT SSI Criteria section 9
SSI criteria case 3
SSI criteria case 3
SSI criteria case 3
Tennessee Checklists (for Chapter 17 NHSN criteria) Available from http://health.state.tn.us/ceds/hai/ 9999
IAB Intraabdominal Tennessee Checklist
Case 3 COLO MRAT Scenario #2 5/15/13: A 60 year-old female admitted with an acute abdomen. Patient sent to OR and finding was a ruptured diverticulum with fecal contamination of the abdominal cavity (wound class 4). A colectomy is performed with a colostomy is formed. Incision is loosely closed with staples to allow for drainage. Antibiotics ordered. 5/19/13: Patient progressing well; afebrile; with decreasing abdominal pain; discharged home 5/25/13: Patient presents to ED with fever of 38.5 C; abdominal pain; CT scan suspicious for small abscess in the intraabdominal space; MD starts antibiotics; patient discharged. No cultures obtained. Discharge note states patient returned with possible intraabdominal abscess.
SSI criteria case 3
SSI criteria case 3
SSI criteria case 3
NO NO NO NO NO NO
SSI criteria case 3 Scenario #2 Conclusion NO This case does not meet criteria for an Organ Space SSI with the only finding being an imaging test that was suspicious for an abscess.
Updated NHSN Website www.cdc.gov/nhsn/
Questions?
NHSN website: http://www.cdc.gov/nhsn/
Suggested HANDOUTS SSI protocol for table (n=24, two per table) MRATs COLO and HYST (cases are 3 COLO and 1 HYST and if they want one extra make 4 COLO and 2 HYST copies for each attendee) Selected TN checklists for O/S (Just need an IAB) Copy of presentation without answers Handout at the END: Copy of presentation with answers