Today’s Webinar will begin at 11 PST

11/29/12

Do You Speak SIR? Using your SSI SIR data to drive improvement

November 29, 2012

Introduction

• Please do not put your phone on hold; use the mute function or *6

• Please type questions or comments into text box

• If time permits, we will open up the phone lines at the conclusion of the presentation

Using Data to Drive

Improvement

On Death, Dying & Data

DENIAL

ANGER

BARGAINING

DEPRESSION

ACCEPTANCE

Connie Cutler, RN, MS, CIC, FSHEA

Main Line Health Bryn Mawr Hospital

Lankenau Medical CenterPaoli Hospital

Riddle Hospital

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NHSN’s Definition of a SIR

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Standardized Infection Ratio

S I R =Observed (by IP Surveillance)

Expected (by NHSN)

Standardized Infection Ratio

Simple MATH (a fraction)

Observed (# SSIs found through surveillance) Expected (# SSIs that NHSN predicted)

• It’s all about comparison to the number 1• SO, if Observed = Expected, result is 1 and that means SIR

is equal to (same as) CDC’s National Healthcare Safety Network

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Standardized Infection Ratio

• If surgery or surgeon is less than ONE, there are less SSIs than the comparative NHSN database

• If higher than ONE, there are more SSIs than the comparative NHSN database

• How much more? Depends on number…– 0.9 = 90% of expected OR 10% better than NHSN– 1.4 = 140% of expected or 40% worse than NHSN– 1.0 = 100% of expected or same as NHSN

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Numerators (infections) and Denominators (cases) for 6 procedures have been required by PA to be reported through the CDC’s National Healthcare Safety Network (NHSN).

Colon Surgeries have been added for 2012.

End of Quality Year Dashboard (April 2011-March 2012)

12 Months of SIRsNumerators (infections) and Denominators (cases) for 6 procedures have been required by

PA to be reported through the CDC’s National Healthcare Safety Network (NHSN). Colon Surgeries have been added for 2012.

New Dashboard

Numbers of Surgeries with SIRs• Cardio-Thoracic Surgery Procedures

– Cardiac Valve– CABG with one incision– CABG with two incisions

• General Surgery Procedures– Appendectomy– Lap Cholecystectomy– Open Cholecystectomy– Lap Colectomy– Open Colectomy– Exploratory Abdominal Surgery– Vascular Bypass Surgery– Vascular Graft/Fistula/AV Shunt

• OB/GYN Categories– Cesarean Section– Abdominal Hysterectomy– Vaginal Hysterectomy

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• Orthopedic Categories– Laminectomy– Knee Prosthesis– Hip Prosthesis

• Neurosurgery Procedures– Laminectomy

• Plastic Procedures– Breast Implant– Breast Lumpectomy– Mastectomy

• Specialty Categories– Esophageal Resection– Kidney Transplant– Lung Resection– Pacemaker– Pacemaker/ICD Insertion

Infection Prevention is providing data on these 26 procedures

Goal: Zero SSIs

• We have committed to– implementation of evidence-based

“bundles” for all patients undergoing surgical procedures• special focus on cardiac and

orthopedic –Feedback on SIR is provided to

surgeons quarterly

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Accomplishments

• Infection Prevention system & division chiefs of surgical specialties –explain SIR–distribute surgeon-specific data–discuss best practices

Accomplishments

• Individual hospitals continue to address issues where their SIR is above NHSN‘s benchmarks (1.0, 0.75, 0.5 are our 3 goals)

Risk-Stratification

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Surgeon-Specific SIR Report

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Two examples of SIRs

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Two examples of SIRs

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Target

Target

Total Hips/Knees SIRs for 3+ years

Vicky Brinsko, Director IP Vanderbilt University

Leaping Into Surgical SIR’s

Moving to SIRs

• Big Changes from CDC/NHSN and CMS• In Jan 2012, CMS requires reporting of

SSIs from Colon Surgery (COLO) and Abdominal Hysterectomy (HYST) as part of their pay for performance program

• Up until this point CDC via NHSN was providing benchmarks for “comparison” to a pooled mean

• In January 2012, CDC switched to SIRs for SSIs

Anticipating Change

• At VUMC we knew this change was coming• We began preparing our surgeons for this change in late

2011– Baby steps– Announced in November 2011 that VUMC easing in to SIRs for

surgical infection data reporting

i n fec t i on c o n t r o l a n d h o s p i t a l e p i d e m i olo gy o c t o b e r 2 0 1 1 , v o l . 3 2, n o . 1 0

o r i g i n a l a r t i c l e

Improving Risk-Adjusted Measures of Surgical Site In fec tio n for the National Healthcare Safety Network

Y i M u , P h D ; 1 Jo n a th a n R . E d w a rds, M S ta t ; 1 Tere s a C . H o r a n , M P H ; 1

S a n d ra I . Berrios-To rre s , M D ;1 Scott K . F r id k in , MD1

Infect Control 2006;27:1330–1339. Hosp Epidemiol 2002;23:372–376.

Standardized Infection Ratio (SIR)

• Ratio of observed events to expected events• Expected events =

The expected number CDC calculates in NHSN• SIR = 1 infection rate at benchmark• SIR < 1 infection rate lower than benchmark• SIR > 1 infection rate higher than benchmark

Summary Data

Are the Data Risk Stratified?Procedure code

Description List of variables

AAA Abdominal aortic aneurysm Emergency, wound class, ASA score, duration AMP Limb amputation Bed size, duration APPY Appendectomy Emergency, endoscope, gender, ASA score, wound class AVSD Arteriovenous shunt for dialysis Age, duration BILI Bile duct, liver or pancreatic surgery Emergency, endoscope, ASA score, wound class, bed size, duration BRST Breast surgery ASA score, bed size, duration CABG Coronary artery bypass graft Anesthesia, gender, medical school affiliation, ASA score, bed size, age, duration CARD Cardiac surgery ASA score, wound class, age, duration CEA Carotid endarterectomy CHOL Cholecystectomy Emergency, endoscope, ASA score, wound class, age, duration COLO Colon surgery Anesthesia, endoscope, gender, ASA score, wound class, bed size, age, duration CRAN Craniotomy Trauma, bed size, age, duration CSEC Cesarean delivery Body mass index, age, anesthesia, ASA, duration, labor, bed size, wound class, emergency FUSN Spinal fusion Anesthesia, gender, medical school affiliation, trauma, wound class,

diabetes,

Infect Control Hosp Epidemiol 2011;32(10):970-986

Monthly Reports to Surgery

• We provide monthly reports of surgical data to the Pod Leaders (see example)

• We present these data as a summary in the Perioperative Surgical Enterprise meeting

Fictional data used for illustration purposes

New Reporting Metrics

• In July (beginning of our fiscal year), we presented a tandem report

• This report had the “old” graph they were used to seeing (without the CDC benchmark featured)

Fictional data used for illustration purposes

New SIR Addition

• We included both the altered familiar graph and the new SIR graph with an explanation

• Surgeons are visual and having both graphs in tandem was helpful

SSI Infections Rates for Pod 1 Abdominal Hysterectomy

Analysis: The overall rate displays a downward trend. The Upper Limit is 4.9 infections per 100 procedures. The 2008 CDC benchmark is 4.1 infections per 100 procedures. The Vanderbilt mean (blue line) is 2.8 infections per 100 procedures The Lower Limit is 0.7 infections per 100 procedures. The infection rate for 2012 Quarter 3 is incomplete 2.4 infections per 100 procedures. The new risk-adjusted Standardized Infection Ratio (SIR) for the identical time period is represented in the graph below. The national benchmark is 1.0. The Centers for Disease Control and Prevention calculates the SIR individually for each procedure and provides an expected number of events based on the specific risk makeup of the denominator population. The variables included in the Abdominal Hysterectomy risk model are anesthesia, endoscope, ASA score, wound class, and duration of surgery. The SIR for Hysterectomy 2012Q3 is 1.017 which is not different than 1.

DEFINITIONS: Vanderbilt Infection Control and Prevention follows the CDC definitions for surgical site infections. These definitions are available at www.cdc.gov/nhsn. CDC-Defined Procedure Type: HYST: Abdominal hysterectomy. Removal of uterus through an abdominal incision. HYST ICD-9 Procedure codes captured: 68.31,68.39,68.41,68.49,68.61,68.69

SSI-Rate: Number of patients with surgical site infection per 100 procedures. The rate reflects the number of CDC defined Surgical Site Infections divided by the number of cases selected by ICD-9 Procedure Code. Standardized Infection Ratio (SIR): The risk adjusted calculation comparing observed infections to predicted infections; standard=1 >1 worse than expected <1 better than expected. Upper Limit: One Standard deviation above the mean (average). Mean (average): Sum of a list of infections divided by total number of procedures. Lower Limit: One Standard deviation below the mean (average). Standard Deviation: A measure of the variation of the observations Methodology: All cases for ICD-9 codes are reviewed using CDC-defined surveillance procedures KEY REPORTING COMMITTEE: Perioperative Enterprise Committee, OR POD Reports DATA SOURCE: Medipac coding data and manual chart review by infection preventionists. Infection Preventionist Assigned: Tracy Louis RN, MSN, CIC

2.4

4.9

2.8

0.70.01.02.03.04.05.06.07.0

Infe

ction

s pe

r 100

pro

cedu

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Hysterectomy Infection Rates

Abd Hyst Upper Limit Average Lower Limit Linear (Abd Hyst)

1.017

00.5

11.5

22.5

3

HYST SIR CDC Benchmark Linear (HYST SIR)

HYST SIR

Change is Good

Amy Nichols, RN, MBA, CIC

Using NHSN’s Standardized Infection Ratio

The UCSF ExperienceAmy Nichols, RN, MBA, CIC

Amy Nichols, RN, MBA, CICDirector

November 2012

Hospital Epidemiology and Infection Control

What is the Standardized Infection Ratio?

• Observed/Expected events– Expressed as decimal– Accompanied by significance statistics– Calculated by National Healthcare Safety Network

database• Calculations are based upon the 2009 NHSN report (data from 2006-2008)• 2009 report reflects information reported from about 600 reporting

hospitals• Now, NHSN has about 4500 reporting hospitals

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SIR at UCSF

• Initially calculated quarterly for Surgical Site Infection (SSI) reports, now rolling monthly

• Annually reported for Device-Related Infection (DRI) surveillance reports– Central Line-Associated Bloodstream Infections

(CLABSI)– Catheter-Related Urinary Tract Infections (CAUTI)– Not reported for Ventilator-Associated Pneumonia

(VAP)

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UCSF SSI SIR Display

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CATEGORY # Procedures # SSI Rate SIR* P-Value 95% CI

Abdominal Aortic Aneurysm 27 0 0.00 0.000 0.2415 2.596

Appendectomy 222 3 1.35 0.722 0.40340.149, 2.109

Biliary Surgery 397 23 5.79 0.530 0.00050.336, 0.795

UCSF CLABSI SIR Display

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UCSF CAUTI SIR Display

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SIR-Based Strategy Implementation

• SSI– Focus away from abdominal and transplant surgeries – Focus on procedures with SIR >1– No procedures were significantly above expected

• CLABSI – Reduction strategic work plan unchanged– No different than expected, but events still occur– Irreducible minimum achieved?

• CAUTI– Reduction strategic work plan unchanged– Rates reducing

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Upcoming Beyond SCIP Events

• Join us for a FREE Webinar• December 18, 2012• 11:00 AM - 12:00 PM• Sue Barnes from Kaiser Permanente• SSI Prevention: How we are doing based on

direct IP observations• www.cynosurehealth.org

www.cynosurehealth.org

Thanks for joining us today