Surgical Site Infection Monitoring Inconsistent

Larry Hand

December 02, 2014

A single surgical site infection (SSI) monitoring system needs to be developed to replace the duplicative efforts currently used by hospitals, according to an article published online November 26 in JAMA Surgery.

Mila H. Ju, MD, from the Division of Research and Optimal Care at the American College of Surgeons (ACS) in Chicago, Illinois, and colleagues analyzed data on colon SSIs from a pilot sample of 16 hospitals during 2012 and compared SSI rates for the ACS National Surgical Quality Improvement Program (ACS NSQIP) with SSI rates for the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

The ACS NSQIP rates were always higher than NHSN rates, and the mean difference came to 8.3% among the hospitals. Of the 16 hospitals, 11 were teaching hospitals with 500 or more beds and two had fewer than 300 beds. All were nongovernmental and nonprofit.

The NHSN collection methods differed among the hospitals, and SSIs managed as outpatient cases often went unreported, whereas outpatient cases were all reviewed for ACS NSQIP.

The researchers conclude that colon SSI rates cannot be used interchangeably in evaluating hospital performance and in determining reimbursement.

Medicare's Hospital Inpatient Quality Reporting program publishes NHSN colon SSI rates on the Hospital Compare website and has tied payments to them in the Medicare Hospital Value-Based Purchasing program since February 2013.

The 16 hospitals had noticed inconsistencies in the data between the two systems and volunteered to participate in this study. The researchers conducted interviews with hospital infection preventionists to determine how they collect data for the NHSN. Data for the ACS NSQIP are standardized.

The researchers found that

  • at least six hospitals used some form of electronic triggering to alert an infection preventionist to review possible cases;

  • some institutions did not have an electronic triggering system, and the preventionist would review daily microbiology reports;

  • preventionists were assigned to certain procedure groups at some hospitals but had no assigned roles at other hospitals; and

  • one hospital did not share its NHSN observed rate.

"[W]e found considerable differences in the implementation between the 2 programs, with marked variation in that of the NHSN," the researchers write.

"These discrepancies come at a time when hospitals are experiencing intense pressure to save money and improve the quality of care."

They conclude: "It is imperative to establish one reliable method for SSI monitoring. The current state is likely hindering hospital improvement efforts by adding unnecessary confusion to the already complex task of measuring perioperative performance. Hospitals are potentially spending unnecessary time and resources collecting duplicative data and being distracted by discrepancies in reports."

"Scratching the Surface"

Although SSI prevention has been a national priority for more than a decade, little evidence points to reduced SSI rates, Mary T. Hawn, MD, MPH, from the Center for Surgical Medical Acute Care Research and Transitions, Birmingham Veteran Administration Hospital, Birmingham, Alabama, writes in an invited commentary.

"[T]he national focus for surgical quality measurement is shifting toward measuring and reporting outcomes, with SSI leading the way," she writes.

"This is a move in the right direction because outcomes are what really matter," she continues. The current article "highlights another important issue related to measuring outcomes: how to define when an event has occurred.... [I]t is unclear whether both systems are true and measuring different surgical populations using different definitions and end points or whether one system is in fact inferior."

She concludes, "The US Patient Protection and Affordable Care Act mandates that we measure and pay for quality, but we are just scratching the surface on how to best achieve this task."

Dr Ju has reported receiving a stipend that is partially supported by the National Institutes of Health and the American College of Surgeons Clinical Scholars in Residence program; Dr Hall has reported being a paid consultant for the American College of Surgeons. The other coauthors and Dr Hawn have disclosed no relevant financial relationships.

JAMA Surg. Published online November 26, 2014. Article abstract, Commentary extract


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