Public Health England (PHE)

Recommendations

For

Surgical Site Infection Surveillance

(SSIS)

Sian HarrisVascular Clinical Nurse Specialist in Wound care & Surgical site infection

Imperial College Healthcare NHS Trust

Background

The most common hospital acquired infections (HAI) include:

Urinary tract infection

Pneumonia

Blood stream infections

Clostridium Difficile

Surgical site infection

As a result surgical site infections have been associated with significant morbidity and approximately account to 16% of all hospital acquired infections and predicted to double if patients have: ⁵

A prolonged hospital length of stay

Which has considerable cost implications to the organisation.

Surgical Site Infection Surveillance Service

(SSISS)

Introduction to Surgical Site Infection Surveillance

Participation ⁴

• 429 hospitals in England registered (258 NHS, 171 independent sector)

• 17 categories of surgical procedure

• DH mandated surveillance in orthopaedics from April 2004 (NHS); all

other categories voluntary

• Independent sector must undertake surveillance and publish SSI risk

from 2016 as per CMA order

• Prospective surveillance – data submission by set deadlines

• Hospitals preselect (voluntary) categories according to own priorities

• Hospital data not publicly reported apart from orthopaedics

• Approx. 200 000 records submitted/year

Patient data collected under Regulation 3 (Surveillance and control of public health hazards explicitly including infectious disease) of the Health

Service (Control of Patient Information) Regulations of 2002 under the powers given to Secretary of State in Section 251, NHS Act 2006

What is a Surgical Site Infection?

A surgical site infection is a type of healthcare-associated

infection in which a wound infection occurs after an

invasive (surgical) procedure. ³NG125 guideline 2019

A surgical site infection occurs when micro-

organisms get into the part of the body that has been operated on and multiply in the tissues. ⁵PHE guidelines 2013

A Surgical site infection is an infection that occurs within 30 days after the

operation, and involves the skin and subcutaneous tissue of the incision

and/or the deep

soft tissue of the incision, and/or any part of the

anatomy (for example, organs and spaces) other than the incision that

was opened or manipulatedduring an operation. ⁶WHO guidelines 2018

Surgical site Infection- Superficial/

Deep/Organ/ Space

Occurs within 30 days of surgery (with/ without an Implant)

Involves Skin or subcutaneous tissue

Involves fascial or muscle layers

Involves any body cavity that was opened/ manipulated during surgery

Must meet at least one of the following criteria

1. Purulent discharge from wound incision

Colour

Consistency

2. Culture of organisms and pus cells present:

Fluid/ tissue sample

Wound swab

3. At least 2 symptoms of inflammation:

Pain, tenderness, localised swelling, redness, heat,

Generally unwell or pyrexia

Abscess/ other evidence of infection in deep incision/ Organ/Space

Re-operation/ histopathology/ radiology

4. Clinicians diagnosis of a Surgical site Infection

1.

2.

3.

Surveillance database

Patients personal details

Surgical procedure- American Society Anaesthesiologists Score (ASA), OPCS

codes, wound class, and operation duration

Antimicrobial prophylaxis, multiple surgical procedures and post discharge follow up survey

Public Health England database is split into three main sections. ⁵

Participating Hospitals In the

Surveillance programme

Orthopaedics is a mandatory

requirement from DH to

undertake surveillance and

have four surgical categories to choose from: ⁵

Hip replacement

knee replacement

Repair of neck of femur

Reduction of long bone

fracture

80%

20%

15%

Data provided by Public Health England (2019) Surgical Site Infection Surveillance Service (SSISS).

National benchmarks

0.0 2.0 4.0 6.0 8.0 10.0

Knee replacement

Hip replacement

Breast surgery

Reduction of long bone fracture

Repair of neck of femur

Cardiac surgery (non-CABG)

Spinal surgery

Abdominal hysterectomy

Cranial surgery

Gastric surgery

Cholecystectomy

Vascular surgery

Limb amputation

Coronary artery bypass graft

Small bowel surgery

Bile duct, liver or pancreatic surgery

Large bowel surgery

SSI risk (%)

SSI risk by category of surgery, England, April 2013 – March 2018

2.7% (2.0-3.5)

2.5% (2.1-2.9)

Y-axis is arranged from

highest SSI risk to lowest, with

the hip and knee SSI risk now

being quite low

X-axis shows the SSI risk

%

2017 Q3 2017 Q4 2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

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National benchmark Hospital A

Data provided by Public Health England (2019) Surgical Site Infection Surveillance Service (SSISS).

Using surveillance data

Hospitals can draw comparisons to the benchmark and

assess their risk of SSI over time

This trend graph shows an anonymized hospital compared

to the National benchmark for Vascular surgery

The Y-axis is based on in-patient and

re-admission detected SSI

The X-axis shows time displayed on a Quarterly

basis (3 month surveillance periods) from March

2017- February 2019

Risk Factors of SSI

<25 kg/m2

25-29.99 kg/m2

≥30 kg/m2

0.0 1.0 2.0 3.0 4.0 5.0

Inpatient/readmission SSI risk following vascular surgery (%)

Hospitals can better understand their

results by assessing important risk

factors such as patient BMI

Patients with high BMI are at increased risk

of developing SSIs for the following reasons:

usually have poor nutrition

Increase risk of dehiscence

co-morbidities (diabetes, respiratory

problems, reduced mobility etc.)

all of which can cause delay in healing and

infection

Things to consider before the

implementation of PHE SSIS

Follow up Clinics with doctors- Communicating diagnosis of SSI

G.P Surgeries

District nurses

Wound swabs

Geographical area

Resources- staff to be trained in SSIS

Documentation of level of infection/ photos- Superficial, Deep incisional, organ/space SSI

30 day follow up or 1 year follow up for implants

North west London

Catchment Area ³

Central and North West London NHS Foundation Trust

Central London Community Healthcare NHS Trust

Central London (Westminster) CCG

Chelsea and Westminster Hospital NHS Foundation Trust

Ealing CCG

Hammersmith and Fulham CCG

Harrow CCG

Hillingdon

CCG

Hounslow CCG

West London (London Borough of Kensington and Chelsea and Queen’s Park and Paddington) CCG

Brent CCG

Care Information Exchange

Is a portal also known has Patients Know Best and aims to provide the patient

with online access to their own healthcare records

The record can be shared with any other health professional involved in the

patients care or a family/ carer

The record is hosted within the NHS secure network

Care Information

Exchange

36,665 patients

How the Care Information Exchange (CIE)

will be used in vascular

On Discharge- Patients will have a wound care management plan

The dressing product and regime will be shared with community health professionals.

Wound Photographs will be uploaded onto the patients record

Encourage self-care

Patients can monitor their wounds against a traffic light system

How to monitor the Wound

This traffic light system provides a visual

aid to patients,of how to monitor their

wound

It provides clinical signs and

symptoms

Contacts numbers and health

services that they can access

Wound care Plan

Provides an overview of the care plan

Dressing plan and frequency of

dressing change

Contact numbers and email

address

Contact details for the

pharmacy department

Wound pictures so that

wounds can be compared

post discharge

Next Steps For Vascular

SSI SurveillanceTo implement the Clinical information exchange portal:

This is to aid a safe patient discharge

Provide robust follow up for 30 days and 1 year for implants

Reduce hospital length of stay

Reduce cost implications to the Trust

To invite G.P surgeries and District nurses to register on the CIE portal:

Effective communication between primary and secondary care sector

Utilising the same system to see the patients care pathway

Patient engagement:

To empower patients to self care

Reduce any unnecessary anxiety or stress upon discharge

To provide better patient education and awareness- of the signs and symptoms of a SSI and who to contact if they need support

Summary

To collaboratively bench mark against other Vascular services around the country

To maintain database collection for PHE by using the CIE portal

To compare re-admission rates due to SSI with previous years

Network with the primary care sector and work in partnership

To prevent re-admissions to hospital and re-interventions

To reduce cost implications to the organisation

Better quality of life for the patient

References

1.) Data provided by Public Health England (2019) Surgical Site Infection Surveillance Service (SSISS).

2.) National Institute for Health and Care Excellence (2019) Surgical Site Infection: prevention and treatment [NG125]. London: National Institute for Health and Care Excellence. Available from: https://www.nice.org.uk/guidance/ng125/chapter/Context [accessed 10 October 2019].

3.)Imperial College Healthcare NHS Trust (2019) West London Sustainability and transformation partnership (STP). Available at: https://www.england.nhs.uk/integratedcare/stps/view-stps/north-west-london/North [accessed 10 October 2019].

4.) Patient data collected under Regulation 3 (Surveillance and control of public health hazards explicitly including infectious disease) of the Health Service (Control of Patient Information) R5.)Regulations of 2002 under the powers given to Secretary of State in Section 251, NHS Act 2006.

5.)Public Health England (2013) Protocol for surveillance of surgical site infection. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment data/file/633775/surgical_site_infections_protocol_version_6.pdf [accessed 10 October 2019].

6.)World Health Organisation (2018) Protocol for surgical site infection surveillance with a focus on settings with limited resources. Available from: https://www.who.int/infection-prevention/tools/surgical/SSI-surveillance-protocol.pdf [accessed 10 October 2019].

Contact details

Sian Harris – Clinical Nurse Specialist Wound care/ Surgical site infection

Email address: sian.harris4@nhs.net

Telephone Number: 02033126666 extension: 25332

Mobile Number: 07913428351