5: Surgical Procedure and SSI Surveillance Methods Survey (with Key)

Appendix 2.5: Surgical Procedure and SSI Surveillance Methods Survey (with Key)

Instructions: Administer this survey to the person who oversees NSHN SSI surveillance and reporting of surgical denominator (surgical procedure) data Facility org ID:

Name / ID of individual

Position:

Interviewer initials:

Date of survey:

interviewed:

IP Other (explain):

Procedure (Denominator) Data

1) Does your facility normally upload surgical procedure

□ Electronic (skip to Q3)

□ Manual

data electronically to NHSN, or is procedure data

□ Other (comment):_______________________

entered manually? (choose one):

2) If manual, who has primary responsibility for surgical

□ IP

If IP is responsible for entering denominator data

□ Clerical/support staff

procedure data entry to NHSN? (choose one):

and unable to fully meet other responsibilities,

□ Clerical/support staff with IP oversight

please recommend clerical support for this task

□ Other ____________________

3) What source(s) of information does your facility

□ The complete OR records/reports system

Discussion for Q 3 and 4: Medical records

NORMALLY use to identify COLO and/or HYST

□ coder opinion is regarded as technical gold

Selected flagged/filtered OR records/reports

standard for identifying NHSN procedures,

procedures? (choose all that apply):

□ CPT codes assigned by surgeons □ but may be questioned if other sources are

ICD-10-PCS procedure codes assigned by coders after

inconsistent, and is often not as timely as

discharge

OR systems. Presence of designated ICD-10-

□ Vendor system using OR records (specify)

PCS procedure code is considered a requirement of NHSN procedure.

□ Vendor system using ICD-10-PCS procedure codes assigned

Planned OR schedules are often inaccurate

after discharge (specify)

due to inability to predict procedures. OR

records systems may be imprecise (e.g., may

□ record XLAP rather than specifying that

Vendor system using both OR records and ICD-10--PCS

XLAP led to COLO, APPY, or SB). OR notes

procedure codes assigned after discharge (specify)

may be coded inaccurately; e.g.; surgeon may call procedure VHYS based on route of

extraction whereas coder may classify as HYST based on route of detachment.

□ Other _______________________________________

4) How do you assure COLO and/or HYST procedure

□ No systematic way

Cross-referencing of sources (e.g.: OR

reporting is complete? □ records plus ICD-10-PCS procedure codes Extra scrutiny to XLAPs assigned after discharge) is probably the □

Cross-reference data sources

best way to assure complete denominator.

(explain):_______________________________________

□ In general, XLAPs should be scrutinized by

Other _______________________________________

IPs conducting surveillance for COLO and HYST.

2016 External Validation Guidance and Toolkit; Surveillance Methods Surveys: Surgical Procedure and SSI

6) Under what circumstances do you remove

□ COLO or HYST ICD-10-PCS procedure code was not assigned for

Although questioning of ICD-10-PCS

COLO and/or HYST procedures from NHSN? (choose

the procedure

procedure codes is acceptable, removal of

all that apply): procedures with designated ICD-10-PCS

□ COLO or HYST ICD-10-PCS procedure code was assigned, but IP

believes coder assigned COLO or HYST code in error

procedure code is only acceptable if

□ Incision not primarily closed in OR

procedure does not meet other aspects of

□ Patient did not stay overnight

NHSN procedure definition. Therefore it

□ Infection was present at the time of surgery

would be appropriate to remove procedure

(wound class = CO or D)

if there is 1) no appropriate ICD-10-PCS

□ ASA score was high

procedure code, 2) no primary closure (note:

□ Other _________________________

new definition of primary closure for 2016), 3) not an inpatient (no overnight stay), 4) no incision/scope (Correct answers 1,3,4)

7) If the OR record does not match the listed ICD-10-PCS ____________________

For validation purposes, NHSN recommends

procedure codes, what should you do?

that IPs should bring coding mismatches to coders for review, and should not over-ride coders’ decisions.

8) Which of the following are consistent with the

□ Complete closure of skin with suture

All but the last option are considered

definition of primary closure for 2016 (clarified as of □ Partial closure of skin with staples primary closure in 2016. April 1)? (check ALL that apply)

□ Closure of skin except for wick/drain through

incision □ Closed fascia with incision loosely closed at the skin level □ Closed fascia, with skin layer left open

9) Does your facility conduct NHSN analysis to look at This is recommended practice for facility use longitudinal trends for COLO or HYST SSIs and

of NHSN data

procedures?

10) What would you do if your procedure denominator Recommended: investigate this aggregate this month was dramatically higher from one month

data by exploring the data at a

to the next? patient/procedure level to identify the

reason.

2016 External Validation Guidance and Toolkit; Surveillance Methods Surveys: Surgical Procedure and SSI Surgical site Infection (Numerator) Data Collection Questions

Instructions: Interview individual(s) directly responsible for identifying and reporting SSI data

Date of survey:

Name/ID of individual interviewed:

Position

(circle): COLO, HYST, BOTH

Numerator (SSI Event) Data:

11) If a patient with an SSI is admitted to your facility but the surgical

 Report the SSI to NHSN

Best practice is to report to “hospital A” and

procedure was performed in another hospital

(“hospital A”), what do (if required by the state) to health “hospital A”

 Report the SSI to

you do? (choose all that apply) department. Hospital A should report to

 Report the SSI to the health department

 No external reporting

NHSN.

Comment: _________________________________

12) If you do not report the SSI to “hospital A”, why not?

 HIPAA concerns

If facility cites HIPAA concerns, consider

(choose all that apply)

 Not a priority for IP program

sharing Appendix 7, or CSTE position

 Logistically difficult (which hospital, who

statement 13-ID-09, which contains

to contact)

information from the Office of Civil Rights

 Not required

assuring that sharing SSI information with

Comments:

the originating facility does not violate

HIPAA.

13) If you are contacted by the IP from another hospital regarding a patient

 Ask the IP for help completing the NHSN

The other IP can best document the depth of

with an SSI who underwent a procedure in your facility, what do you do? report

infection, but cannot report the event to

(choose all that apply) NHSN because it has to be linked. Suggest

 Document in your tracking records

 Report the SSI to NHSN

asking the other IP to help complete the

 Ask the IP to report the SSI to NHSN

NHSN report form, include a note or a copy

 No internal reporting or documentation

in the patient record, and report to NHSN.

Comment: _________________________________

2016 External Validation Guidance and Toolkit; Surveillance Methods Surveys: Surgical Procedure and SSI

14) What methods are routinely and systematically used to identify possible Reports/Rounds: SSI? (Check all that apply)

□ Emergency department line lists with diagnoses □ Admissions line lists with diagnoses □ Surgical ward rounds □ Positive laboratory cultures from inpatients □ Positive laboratory cultures from ED □ Pharmacy reports (antibiotic starts or continuations) □ Other _________________________________

Surgical service information: □ Inpatient returns to surgery

□ Surgical service readmissions

ADT/Medical Records Data Mining: □ Readmissions within one month of discharge

□ Extended LOS

□ Discharge diagnostic coding □ Other ______________________________

15) How does your facility conduct post-discharge surveillance for SSIs? □ IP does not have a formal post-discharge surveillance plan (check all that apply)

□ IP conducts patient survey by mail □ IP conducts patient survey by telephone □ IP provides line list of patients to surgeon for response □ Surgeon indicates SSIs identified at surgical follow-up □ Surgeon surveys patient by mail □ Surgeon surveys patient by telephone □ IP reviews surgical clinic / wound clinic information □ IP reviews surgical patient records 30-60 days after procedures

Other/ Comment: _____________________________

16) During one trip to the operating room, both a COLO procedure and a

□ COLO

Two answers are correct (a and d): The

□ HYST

HYST procedure are performed. A deep-incisional SSI develops. To

procedure which is higher on the 2016

which procedure should you attribute the SSI? procedure hierarchy (this would be COLO),

□ Both

□ Whichever is higher on the procedure

because you cannot determine which

hierarchy

procedure led to the SSI

□ Neither

2016 External Validation Guidance and Toolkit; Surveillance Methods Surveys: Surgical Procedure and SSI

17) During one trip to the operating room, both a COLO procedure and a

□ COLO

Two answers are correct(a and d): The

HYST procedure are performed. The patient later meets criteria for a GI- □ HYST

procedure which is higher on the 2016

IAB with peritonitis (an organ-space SSI). To which procedure should procedure hierarchy (this would be COLO)

□ Both

□ Whichever is higher on the procedure

because you cannot determine which

you attribute the SSI?

hierarchy

procedure led to the SSI

□ Neither

18) During one trip to the operating room, both a COLO procedure and a

□ COLO

The vaginal cuff is the operative site of the

□ HYST

HYST procedure are performed. An abscess of the vaginal cuff (organ-

HYST, and the hierarchy is not needed; this

space SSI) develops. To which procedure should you attribute the SSI? SSI is attributable to the HYST (answer b).

□ Both

□ Whichever is higher on the procedure hierarchy □ Neither

19) During one trip to the operating room, both a SB procedure and a HYST

□ SB

The SSI is localized to the operative site of

procedure are performed. An abscess of the small-bowel anastomosis

□ HYST

the SB, and the hierarchy is not needed; this

site (organ-space SSI) develops. To which procedure should you SSI is attributable to the SB (answer a). SB is

□ Both

□ Whichever is higher on the procedure

higher on the hierarchy, but the hierarchy is

attribute the SSI?

hierarchy

only used when attribution cannot be

□ Neither

determined by localized infection.

2016 External Validation Guidance and Toolkit; Surveillance Methods Surveys: LabID Event Appendix 2.6: LabID Event Surveillance Methods Survey (with Key)

OrgID / Name of Hospital _______________________________________________________________ __________________________

LabID Event Surveillance Methods Survey

Instructions: Administer this survey to the person who oversees NHSN LabID Event reporting

Denominator Data Collection Questions

Name of individual interviewed:

Position:

□ FacWideIN MRSA

Interviewer

Date of survey:

□ FacWideIN CDI

bacteremia

initials:

1) For FacWideIN reporting, denominator data are entered into NHSN once a month at the

T facility-wide level

□ True

□ False

2) For CDI reporting, the denominator should include all completed CDI toxin tests

□ True

F (denominator =

□ False

admissions and patient days)

3) Patient days include only admitted patients on inpatient wards; observation patients

F (all patients housed located on inpatient wards are excluded

□ True

□ False

in inpatient locations)

4) For CDI reporting pediatric locations should be excluded from FacWideIN reporting

□ True

F (NICU and well-

□ False

baby locations and babies on LDRP are excluded for CDI)

5) For MRSA bacteremia reporting baby locations (NICU, newborn nursery, etc) should be

F (no location excluded from the denominator

□ True

□ False

exclusions for MRSA)

Numerator Data Collection Questions

Name of individual interviewed:

Position:

□ FacWideIN MRSA

Interviewer

Date of survey:

bacteremia

initials:

□ FacWideIN CDI

6) For FacWideIN reporting, one monthly numerator for Events is reported at the facility-

F (events are wide level

□ True

reported by location) 7) For CDI reporting, the numerator should include toxin-positive CDI results conducted on

□ False

F (laboratories formed stool specimens

□ True

□ False

should only process and report results for unformed stools)

8) A second event is always reported if >14 days have passed from the most recent positive

T MRSA bacteremia or toxin-positive CDI test result

□ True

□ False

9) A second event is only reported if >14 days have passed from the most recently reported

F (If the patient labID event

□ True