Metrics — Surgical Site Infections

How Will You Know If You're Making a Difference?

Under the rubric of hospital-acquired conditions (HACs), CMS included surgical site infections (mediastinitis following coronary artery bypass grafting) in the original 8 conditions found to excessively increase health care costs and negatively affect quality.¹ In October 2008, these 8 conditions were expanded, as was the category of surgical site infections to include elective surgical procedures and is defined as an infection that develops within 30 days of an operation or within 1 year of an implantable device.¹ At the same time, the Surgical Care Improvement Project was initiated to track parameters and improve quality.²

The importance of defining metrics to track this condition is crucial for designing appropriate preventive measures and success. Based on the preliminary work done by the project team, choose metrics that are easy to abstract (which may differ from institution to institution) and conducive to longitudinal study. Take advantage of data already being studied. A sample of metrics for a surgical site infection improvement project might include:

Outcome measures

• Normothermia prior to procedure.^3—5
• Resolution of pyrexia within 48 hours.³
• Septic complications.³
• Appropriate hair removal.^5—7

Documentation

• Lesion size/cessation of spread of lesion at 48 hours.³
• Handwashing protocol in place?
• Glycemic control protocol in place or glycemic control team notified (see Glycemic Control Resource Room)?

Process measures

• Cultures obtained within first 24 hours of admission.^5,9,10
• Antimicrobial selection.^3—5,9,10
• Prophylactic antibiotic received within 1 hour prior to surgical incision.^3—5,9,10
• Antimicrobials discontinued within 24 hours of surgery end time.^4,5,9,10
• Early wound debridement.³
• Plan for offloading affected area.
• Wound dehiscence rate.³
• Skin graft failure rate.³
• Readmission rate.³

1. CMS. CMS proposes to expand quality program for hospital inpatient services in FY 2009. Available at: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3041. Accessed December 11, 2009.
2. SCIP. Surgical care improvement project (SCIP) core measure set. Available at: http://www.jointcommission.org/assets/1/6/Surgical%20Care%20Improvement%20Project.pdf. Accessed December 11, 2009.
3. FDA. Guidance for industry uncomplicated and complicated skin and skin structure infections — developing antimicrobial drugs for treatment office of drug evaluation IV. Available at: http://www.fda.gov/ohrms/dockets/98fr/2566dft.pdf. Accessed December 11, 2009.
4. Forbes SS, Stephen WJ, Harper WL, et al. Implementation of evidence-based practices for surgical site infection prophylaxis: Results of a pre- and postintervention study. J Am Coll Surg. 2008;207:336—341.
5. HHS. HHS action plan to prevent healthcare-associated infections: Prevention — targets and metrics. Available at: http://www.hhs.gov/ophs/initiatives/hai/prevtargets.html. Accessed December 11, 2009.
6. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006;2:CD004122.
7. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005;190:9—15.
   • Adequate glycemic control pre- and postprocedure.^5,7,8
   • Fewer amputations required; fewer high-level amputations required.⁸
8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital infection control practices advisory committee. Infect Control Hosp Epidemiol. 1999;20:250—278; quiz 279—280.
9. Bratzler DW, Houck PM, Surgical Infection Prevention Guideline Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg. 2005;189:395—404.
10. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: Baseline results from the National Surgical Infection Prevention Project. Arch Surg. 2005;140:174—182.