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:

  • to lower the incidence of SSI by encouraging the owners of the problem (primarily the surgical staff) to:
    • comply with existing guidelines and good surgical practice;
    • correct or improve specific practices;
    • develop, implement and evaluate new preventive practices;
  • participation to the European network will also produce gains at local level from international comparisons that may provide insights that would not be revealed by surveillance limited at the regional or national level.

 At level of regional or national network coordination:

  • to provide the units with the necessary reference data to make comparisons of risk-adjusted rates between units/hospitals:
    • to follow-up epidemiological trends in time;
    • to identify and follow-up risk factors of SSI;
    • to improve the quality of data collection.

 At European level

  • to monitor and describe the epidemiology of SSI in the European Union in view of responding to the objectives of Decision 2119/98/EC of the European Parliament and of the European Council;
  • to follow-up the incidence and the geographical spread of SSI for a selection of surgical procedures;
  • to identify regions or countries at higher need of European Union support with regard to surveillance and control of healthcare-associated infections;
  • to ensure communication of relevant data on healthcare-associated infections to the European Commission as a complement to the data transmitted by the national health authorities;
  • to facilitate the communication and the exchange of experience between national/regional networks for the surveillance of healthcare-associated infections;
  • to stimulate the creation of national/regional coordination centres for the surveillance of SSI where these centres/networks do not exist;
  • to provide methodological and technical support to the national/regional coordination centres;
  • to improve surveillance methodology, data validation and utilisation;
  • to validate risk factors of SSI at the European Union level;
  • to explore the correlation between structure and process indicators and the incidence of surgical site infections throughout Europe in order to generate hypotheses and new insights in healthcare-associated infection control.

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Link to European IC/HH Core Competencies

Area 3. Surveillance and investigation of healthcare associated infection (HAI)

 

References

http://www.ecdc.europa.eu/en/activities/surveillance/HAI/about_HAI-Net/Pages/SSI.aspx

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:

  1. Patient-based (or “standard”) protocol: patient-level data are collected for each patient/operation, whether there is an infection or not. The data includes risk factors that allow for risk-adjusted, inter-hospital comparisons.
  2.  Unit-based (or “light”) protocol: selected patient-level data are only collected for infected patients. Denominator data are collected by operation category (number of operations and postoperative patient-days).

 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:

  • definitions of surgical site infections (numerator) (see ECDC “Point prevalence survey of healthcare associated infections and antimicrobial use in European acute care hospitals” protocol, Surgical Site Infection (SSI) definition);
  • inclusion and exclusion criteria, (population under surveillance and type of surgery under surveillance) (denominator);

 and gives information about some tools for  the data analysis: Basic SSI risk index

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Link to European IC/HH Core Competencies

Area 3. Surveillance and investigation of healthcare associated infection (HAI)

 References

http://www.ecdc.europa.eu/en/publications/publications/120215_ted_ssi_protocol.pdf

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:

  • operation lasting more than the duration cut point hours, where the duration cut point is the approximate 75th percentile of the duration of surgery in minutes for the operative procedure, rounded to the nearest whole number of hours;
  • contaminated (class 3) or dirty/infected (class 4) wound class;
  • ASA classification of 3, 4, or 5

Calculation of basic SSI risk index

 

Calculation

Score =0, if:

Score=1, if:

Wound contamination class

W1, W2

W3, W4

 

ASA classification

A1, A2

A3, A4, A5

 

Duration of operation T =  75th percentile of the duration of surgery in minutes for the operative procedure

 

 

≤ T

> T

 

 

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

_____ 

Link to European IC/HH Core Competencies

Area 3. Surveillance and investigation of healthcare associated infection (HAI)

References

  1. NNIS Manual, May 1999. Surgical patient surveillance component: Part XI-3
  2. Gaynes RP. Surgical Site Infections and the NNIS SSI Risk Index: room for improvement. Infect Control HospEpidemiol 2000;21(3):184-5
  3. Culver DH, Horan TC, Gaynes RP et al. Surgical wound infection rates by wound class, operative procedure and patient risk index. Am J Med 1991;91(suppl 3B):152S-7S.

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:

  • W1: clean wound is an uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow non-penetrating trauma should be included in this category.
  •  W2: clean-contaminated wounds are operative wounds in which the respiratory, alimentary, genital or uninfected urinary tracts are entered under controlled condition and without unusual contamination. Specifically operations involving the biliary tract, appendix, vagina and oropharynx are included in this category provided no evidence of infection or major break in technique is encountered.
  •  W3: contaminated wounds include open, fresh, accidental wounds. In addition operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, not purulent inflammation is encountered are included in this category.
  •  W4: dirty or infected wounds include old traumatic wounds with retained devitalised tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation

 

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Link to European IC/HH Core Competencies

Area 3. Surveillance and investigation of healthcare associated infection (HAI)

References

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):

  • ASA 1:  Normally healthy patient;
  • ASA 2:  Patient with mild systemic disease;
  • ASA 3:  Patient with severe systemic disease that is not incapacitating;
  • ASA 4:  Patient with an incapacitating systemic disease that is a constant threat to life;
  • ASA 5:  Moribund patient who is not expected to survive for 24 hours with or without operation.

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Link to European IC/HH Core Competencies

Area 3. Surveillance and investigation of healthcare associated infection (HAI)

References

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.

 

NHSN

Category

Description

75th percentile cut-off value, in hours

CABG

Coronary artery bypass graft, unspecified

5

CBGB

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

5

CBGC

Coronary artery bypass graft with chest incision only: chest procedure to perform direct vascularisation of the heart using, for example, the internal mammary artery

4

CHOL

Cholecystectomy: removal of gallbladder; includes procedures performed using the

laparoscope

2

COLO

Colon surgery: incision, resection or anastomosis of the large bowel; includes large-tosmall and small-to-large bowel anastomosis

3

CSEC

Caesarean section

1

HPRO

Arthroplasty of hip

2

KPRO

Arthroplasty of knee

2

LAM

Laminectomy: exploration or decompression of spinal cord through excision or incision into vertebral structures

2

 

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Link to European IC/HH Core Competencies

Area 3. Surveillance and investigation of healthcare associated infection (HAI)

References

 

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: 

  •  the population under surveillance:
    • all data from hospitals (or specific wards within a hospital) that perform procedures included in the European protocol are eligible for inclusion;
  •  the type of surgery under surveillance (table 1):
    • in order to obtain sufficient numbers of records allowing statistically valid conclusions, the diversity of operations to be recorded is limited and focuses on relatively frequently registered procedures that are likely to be interpreted similarly in different settings..

 

NHSN Category

Description

ICD-9-CM*

Codes included in the category

COLO

Colon surgery

Incision, resection or anastomosis of the large bowel; includes large-to-small and small-to-large bowel anastomosis

Laparoscopic excision of large intestine

Enterotomy

Intestinal anastomosis

Abdominoperineal resection of rectum

Transsacralrectosigmoidectomy

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

CHOL

Cholecystectomy

Removal of gallbladder, includes procedures performed using the laparascope

51.0,51.03, 51.04,51.13, 51.2–51.24

HPRO

Arthroplasty of hip 

00.70–00.73, 81.51–81.53

KPRO

Arthroplasty of knee

00.80–00.84, 81.54–81.55

LAM

Laminectomy

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

CSEC

Caesarean section

74.0–74.2, 74.4, 74.9–74.99

CABG

Coronary artery bypass, unspecified

36.1–36.2

CBGB

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

36.10–36.14, 36.19

CBGC

Coronary artery bypass grafting with chest incision only

Chest procedure to perform direct vascularisation of the heart using, for example, the internal mammary artery

36.15–36.17, 36.2

Table 1

*ICD-9-CM Procedure Codes ver. 2001

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Link to European IC/HH Core Competencies

Area 3. Surveillance and investigation of healthcare associated infection (HAI)

References

http://www.ecdc.europa.eu/en/publications/publications/120215_ted_ssi_protocol.pdf