Surgical site infections (SSIs) are an important target for the surveillance of healthcare-associated infections (HAI). This surveillance is a priority for surveillance in several European countries. SSIs are among the most common HAI. They are associated with longer post-operative hospital stays, additional surgical procedures, may require intensive care and often result in higher mortality.
The ECDC HAISSI protocol for the surveillance of SSIs is based on the surveillance protocol developed by the HELICS (Hospitals in Europe for Infection Control through Surveillance), the ECDC HAISSI protocol was integrated in the European surveillance system (TESSy).
The primary objectives are:
At hospital level:
At level of regional or national network coordination:
At European level
Link to European IC/HH Core Competencies
Area 3. Surveillance and investigation of healthcare associated infection (HAI)
Decision No 2119/98/EC of the European Parliament and of the Council of 24 September 1998 setting up a network for the epidemiological surveillance and control of communicable diseases in the Community. Official Journal of the European Communities 1998:L268/1-6.
Surveillance of surgical site infections in the European hospitals-HAISSI protocol
The ECDC HAISSI (Healthcare Associated Infections Surgical Site Infections) protocol comes in two versions:
To improve the quality of inter-hospital comparisons, infection rates must be risk-adjusted so that variations due to differences in patient case-mix are reduced. Therefore, the patient-based (“standard”) protocol is the recommended method for surveillance.
However, the unit-based (“light”) protocol is less labour intensive and requires less resources. The protocol can be used when surveillance resources are scarce since surveillance of SSIs must be carried out over long periods to stabilise confidence intervals of SSI rates. All indicators generated from data obtained with the unit-based (“light”) protocol can also be generated from data obtained with the patient-based (“standard”) protocol. Therefore, both types of data collection may be combined within a country or even in the same hospital (although not during the same surveillance period).
Case definitions and included patients are the same for both versions, but while in the patient-based protocol risk factors are collected for each patient (infected or not), in the light protocol denominator data are aggregated at the hospital (and optionally surgical unit) level.
The protocol of the project describes the case definitions for numerator and denominator, it standardises:
and gives information about some tools for the data analysis: Basic SSI risk index
NNIS Manual, May 1999. Surgical patient surveillance component: Part XI-3
Gaynes RP. Surgical Site Infections and the NNIS SSI Risk Index: room for improvement. Infect Control HospEpidemiol 2000;21(3):184-5.
Basic surgical site infection risk index (used in the Surveillance of surgical site infections in European hospitals-HAISSI protocol)
Basic surgical site infection (SSI) risk index is the index used in National Healthcare Safety Network (NHSN) and assigns surgical patients into categories based on the presence of three major risk factors, and it is used to predict a surgical patient’s risk of acquiring a surgical site infection.
The index values range from 0 to 3 points and are defined by three independent and equally weighted variables:
Calculation of basic SSI risk index
Score =0, if:
Wound contamination class
A3, A4, A5
Duration of operation T = 75th percentile of the duration of surgery in minutes for the operative procedure
Basic SSI risk index = Sum of scores:
0: absence of risk factors
1: presence of one risk factor
2: presence of two risk factors
3: presence of three risk factors
Wound contamination class (used in the Surveillance of surgical site infections in European hospitals-HAISSI protocol)
The “Surveillance of surgical site infections in European hospitals-HAISSI protocol” adopts the wound contamination class described by Altemeier et al:
Altemeier WA, Burke JF, Pruitt BA, Sandusky WR. Manual on control of infection in surgical patients(2nd ed.) Philadelphia, PA: JB Lippincott, 1984
ASA classification (used in the Surveillance of surgical site infections in European hospitals-HAISSI protocol)
The “Surveillance of surgical site infections in European hospitals-HAISSI protocol” adopts the physical status classification developed by the American Society of Anesthesiology (ASA):
Owens WD, Felts JA, Spitznagel EL. ASA physical status classification: a study of consistency of ratings. Anesthesiology 1978;49(4):239-43
Duration of operation (used in the Surveillance of surgical site infections in European hospitals-HAISSI protocol)
The “Surveillance of surgical site infections in European hospitals-HAISSI protocol” adopts the table below for the calculation of the cut-off values (75th percentile of the duration of surgery in minutes for the operative procedure) of the duration of the selected NHSN procedures. In case of a re-intervention within 72h after the primary procedure, the duration of the re-intervention needs to be added to the duration of the primary procedure.
75th percentile cut-off value, in hours
Coronary artery bypass graft, unspecified
Coronary artery bypass graft with both chest and donor site incisions: chest procedure to perform direct revascularisation of the heart; includes obtaining suitable vein from donor site for grafting
Coronary artery bypass graft with chest incision only: chest procedure to perform direct vascularisation of the heart using, for example, the internal mammary artery
Cholecystectomy: removal of gallbladder; includes procedures performed using the
Colon surgery: incision, resection or anastomosis of the large bowel; includes large-tosmall and small-to-large bowel anastomosis
Arthroplasty of hip
Arthroplasty of knee
Laminectomy: exploration or decompression of spinal cord through excision or incision into vertebral structures
Surveillance of surgical site infections in European hospitals-HAISSI protocol, inclusion and exclusion criteria (population under surveillance and type of surgery under surveillance)
The “Surveillance of surgical site infections in European hospitals-HAISSI protocol” adopts the following inclusion/exclusion criteria to select:
Codes included in the category
Incision, resection or anastomosis of the large bowel; includes large-to-small and small-to-large bowel anastomosis
Laparoscopic excision of large intestine
Abdominoperineal resection of rectum
17.3–17.39, 45.00–45.03,45.15, 45.26, 45.31–45.34, 45.4, 45.41, 45.49, 45.50–45.52, 45.61–45.63, 45.7–45.95, 46.0, 46.03, 46.04, 46.1–46.14,46.20–46.24, 46.31, 46.39, 46.4, 46.41, 46.43, 45.5, 46.51, 46.52, 46.7–46.76, 46.9–46.94, 48.25,48.35, 48.40, 48.42, 48.43, 48.49, 48.5–48.59, 48.6–48.69, 48.74
Removal of gallbladder, includes procedures performed using the laparascope
51.0,51.03, 51.04,51.13, 51.2–51.24
Arthroplasty of hip
Exploration or decompression of spinal cord through excision or incision into vertebral structures
03.0–03.09, 80.50, 80.51, 80.53, 80.54,
80.59, 84.60–84.69, 84.80–84.85
74.0–74.2, 74.4, 74.9–74.99
Coronary artery bypass, unspecified
Coronary artery bypass grafting with both chest and donor site incisions
Chest procedure to perform direct revascularisation of the heart; includes obtaining suitable vein from donor site for grafting
Coronary artery bypass grafting with chest incision only
Chest procedure to perform direct vascularisation of the heart using, for example, the internal mammary artery
*ICD-9-CM Procedure Codes ver. 2001