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Abstract

Surgical site infections (SSI) that are reported to the CDC’s National Healthcare and Safety Network (NHSN) are adjusted and reported as a Standardized Infection Ratio (SIR) based on various risk factors documented in the medical record. One important risk factor includes accurate documentation of wound class. A review of our charts identified that inaccurate documentation of wound class as defined by NHSN led to inflated SIR numbers in our colorectal (COLO) and abdominal hysterectomy (HYST) SSIs. At our 2,247-bed hospital system, we instituted a quality improvement initiative in order to reduce and more accurately reflect a true SSI SIR. Starting in January 2016, our process for COLO & HYST surveillance consists of an Infection Prevention worklist that is reviewed daily for SSI triggers followed by an SSI review team consisting of both campus and system IP and Operating Room leadership. During our review, we provided direct feedback to surgeons and staff regarding documentation and opportunities around our surgical bundle. In addition, we manually reviewed all COLO and HYST cases and corrected inaccurate wound class when identified. For January-October of 2016, we observed a 56% decrease in our COLO SSI rates and a 54% decrease in SIR compared to 2015. Our COLO SSI rates went from 3.26 infections/100 surgeries to 1.28 infections/100 surgeries and the SIR went from 1.14 to 0.46. For HYST SSI, we saw a 19% decrease in both our rate and SIR. Our HYST SSI rates went from 0.34 infections/100 surgeries to 0.22 infections/100 surgeries and the SIR went from 0.45 to 0.30. A multifaceted approach that included a bundled approach to risk factor modification, a multidisciplinary, multilevel review process, and improved documentation led to improved partnerships with our surgeons and decreased SSI rates for both colorectal and abdominal hysterectomies.

Biography

E-mail: fgainson@yahoo.com