This funding allowed Sentara Healthcare to take a systems approach to implementing NHSN surgical site infection (SSI) surveillance. They used $124,000 for information technology assistance to develop an electronic process for exporting surgical procedure data directly into NHSN. They also used $21,000 to train infection prevention and control staff as well as data auditors on SSI surveillance. This funding demonstrated how a large healthcare system can collaborate across departments like IT, infection prevention, and data auditors to efficiently implement NHSN reporting requirements.

1. All About Surgical Site Infections
Lessons learned from the SSI surveillance
pilot, SSI mini grant program, and the data
presentation collaborative
Andrea Alvarez, MPH
HAI Program Coordinator
Virginia Department of Health
Jacqueline P. Butler, CIC
Dir, Infection Prevention & Control
Sentara Healthcare
November 10, 2011

2. SSI Surveillance Pilot:
Purpose
Public reporting expectations increasing
 Multiple factors to consider when choosing
a SSI for public reporting
Troubleshoot issues with surveillance
definitions
Quantify time requirements for
surveillance
Gather lessons to help prepare other
facilities for reporting

3. Perceived Pilot Benefits
Increase awareness of SSIs
 More focus on prevention practices, monitoring
associated outcomes, physician awareness of
surveillance definitions
High profile, high risk, high priority procedures
Providing standardized benchmark data
Prepare for future reporting requirements
 Gain more experience in NHSN data entry
 Increase upload or electronic capabilities
 Quantify the time associated with procedure
surveillance
 Identify demands for reporting to facilitate
processes to reduce burden
Feed data back to those who can make a
difference

4. SSI Pilot: Methods – Selecting
Hospitals and Procedures
Coronary artery bypass graft (CABG), hip
replacement (HPRO), knee replacement
(KPRO) surgeries
 Consumer interest, experiences of other states,
morbidity
Surgical Care Improvement Project (SCIP)
antibiotic measures
 Align process measures with outcome measures
 Pilot feasibility of publicly reporting procedure-
specific SCIP data
18 hospitals
 Randomly selected by bedsize category and number
of procedures performed
Voluntary participation
 Incentives: educational stipend (conferences, journal
subscriptions, etc.)

5. Pre-Survey
18/18 facilities responded (100%)
Well prepared:
 100% enrolled in NHSN and used NHSN definitions
 94% calculated SSI rates
Relatively well prepared:
 2/3 currently collected patient-level information
 Prevention efforts already underway
 SSI surveillance deemed high or medium priority
Not well prepared:
 One facility was currently entering data into NHSN for
the pilot procedure
 No facilities currently uploaded denominator data
 Limited communication between surgical and IP
databases
 50% perceived surveillance to be somewhat or very
difficult

6. Methods - Training
Partnership with APIC-VA for training
and distribution of incentives
One-day training (June 9, 2010)
 Case studies prepared by APIC-VA
Monthly conference calls
 Surveillance Q&A
 Data import discussions
 Feedback of data

7. Some Surveillance Pointers
Definitions – Ensure the latest version of the
definitions are being used
 Deep incisional vs. organ space
 Increases consistency and standardization
SSIs are attributed to the date of the operation
 For SSIs identified on readmission, on the event form
use the date of admission and discharge for the surgery
visit
All surgical procedures must be entered into NHSN
 Not only procedures with an event (like CLABSIs)
Only need to report the required sensitivities
To report a pathogen that is not on the list of common
pathogens, right-click in pathogen field

8. NHSN Clarifications
Deep incisional vs. organ space
 If an incision is opened, the infection is
counted as deep incisional no matter where it
travels
A knee that has never been operated on
before is always a primary regardless of
whether it is a total or partial surgery
Transplant
 Includes internal staples
 Does not include a blood transfusion
SSI standardized infection ratios (SIRs)
only include primary sites

9. Methods – Data Reporting
Monthly entry of procedures and
infection events into NHSN
 Procedures from July – Dec 2010 with 6
months of post-discharge surveillance
Quarterly submission of SCIP data
 Jan-June 2010 (baseline), July-Dec 2010
(pilot)
Time and effort
 Time spent on surveillance
 Number of staff involved with surveillance

10. Electronic Upload Methods:
ASCII File
Comma delimited ASCII file (.txt or .csv)
created by the facility
 Can be generated from different external
sources, such as infection prevention databases
or hospital information systems
 Requires assistance of operating room and/or IT
staff
 Specifications for values, format, and data
requirements must be followed
Specifications and instructions available on
NHSN website:
 http://www.cdc.gov/nhsn/PDFs/ImportingProced
ureData_current.pdf

11. Electronic Upload Methods: CDA
 Clinical Document
Architecture (CDA)
 Health Level 7 (HL7)
standards used to provide a
consistent format framework
for electronic documents
 Not all vendors have the
capacity to create
documents in this HL7
framework
 Specifications and
instructions available on
NHSN website
 http://www.cdc.gov/nhsn/
CDA_eSurveillance.html
 Examples of vendors*
with CDA compatibility:
 Atlas Development
Corporation
 BD Diagnostics (formerly
known as AICE or ICPA)
 CareFusion / MedMined™
from Cardinal Health
 Cerner Corporation
 EpiQuest
 ICNet International Limited
 RL Solutions
 SafetySurveillor® by
Premier
 Sentri7 by PharmacyOne
 TheraDoc Hospira, Inc.
 Vecna Technologies
 VigiLanz Corporation
*List compiled by APIC

12. SSI Pilot: Time and Effort per
Facility
0
5
10
15
20
25
30
35
Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun
Hours
per
facility
(avg)
CABG
HPRO
KPRO
2010 2011*
*Readmission/post-discharge only

13. SSI Pilot: Time and Effort per
Person
0
2
4
6
8
10
12
14
16
18
Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun
Hours
per
staff
member
(avg)
CABG
HPRO
KPRO
2010 2011*
*Readmission/post-discharge only

14. Results: SCIP Data
 SCIP 1: Timely receipt of antibiotic prior to surgery
 SCIP 2: Receipt of appropriate antibiotic
 SCIP 3: Timely discontinuation of antibiotic after surgery
Procedure
SCIP1
(%) SCIP2 (%)SCIP3 (%)
Total
(%) Minutes
CABG 98.6 100.0 97.2 98.6 19
HPRO 99.4 100.0 97.0 98.8 8
KPRO 97.2 99.9 96.9 98.0 12
Total 98.4 100.0 97.0 98.5 13

15. Results: SSIs Identified
 2,388 procedures conducted
 25 SSIs included in SIR calculation
 Secondary infections are not included in SIR
- All CABG (N=5)
 64% CABG, 24% KPRO, 12% HPRO
 ASA score and duration of procedure highest for
CABG
 3 occurred > 30 days after procedure (all KPRO)
 SIR = 0.72
 Interpretation: The pilot facilities identified
28% fewer SSIs than expected based on the
national experience.
 Not statistically significant

16. Post-Survey
14/18 facilities responded (78%)
Facilities more prepared for public
reporting
 Staff review SSI definitions more closely
IT changes
 Many facilities changing or considering
changing vendors
Changes to administration’s prioritization
of SSI surveillance (4 facilities)
No change in IPs’ perspective of the
magnitude of the problem of SSIs in their
facility

17. Benefits to Participation
93% - Helped to prepare for future
reporting requirements
79% - Gained more experience in NHSN
data entry
57% - Facilitated process needed to
meet pilot demands and future reporting
50% - Demonstrated how much time was
associated with HAI surveillance to find
ways to decrease burden on workload
43% - Automated upload and/or
increased electronic capabilities
43% - Increased awareness of SSIs

18. Barriers Encountered
50% Learning curve
 Data entry
 Importing data
43% Time/resource limitations
 Data entry
 Staffing
29% No barriers
14% Post-discharge surveillance
14% Consistency between facilities

19. Electronic Upload to NHSN
Pre-survey: 0 facilities End of pilot: 9 facilities (50%!)
6 facilities submitted feedback on upload process
 4 used Clinical Document Architecture (CDA) technology
- 3 BD/AICE, 1 unspecified vendor
- Decreases in monthly surveillance effort after implementing
CDA
 8 hours to 2 hours
 8 hours to 1 hour
- Time required to set up import averaged several months
 2 used .CSV file
- Decreased monthly surveillance effort in one hospital from 5
hours to 1 hour
- Took 2 months for one hospital to set up its file transmission
 2 hospitals used DICON to help with their electronic import
 4 of these hospitals used Meditech for their patient medical
records

20. Electronic medical record system (EMR)
is necessary for the electronic upload
and any movement towards increased
use of EMR would be of help to the
facility
Helpful to talk to other facilities using the
same systems and see if they have been
able to set up a file transfer
 Sometimes easier for facility IT staff to talk to
each other rather than IP trying to explain to
IT what is needed
Importance of monitoring all exported
data for quality
Lessons Learned / Challenges

21. Lessons Learned / Challenges
Operating room system capability and
compatibility
Writing the data dictionaries – challenge!
 Concern about changing
dictionaries/remapping elements if NHSN
amends definitions or changes required
fields
Team approach required (quality, IT,
other departments)
 Establish importance of support of the
infection prevention program on a local level
first
 IT support is critical for implementation and
to address data quality

22. PERSPECTIVES FROM
THE PARTICIPANTS

23. Experiences of a Large
System
Sentara Healthcare (SH):
 >23,000 staff, >100 care giving sites, including 10
acute care hospitals with a total of 2,349 beds
Sentara Norfolk General Hospital / Sentara Heart
Hospital
 Patients receive comprehensive cardiac services -
from diagnostics to open heart surgery and
transplants.
 State-of-the-art hospital features all-private rooms,
including 112 inpatient beds and 45 pre/post
procedural rooms for patients undergoing
interventional cardiac procedures.
 Houses 5 cardiac operating rooms designed to
accommodate 2,000 cardiac surgeries a year.

24. Timeline of Sentara’s Pilot Period
 Calm down
 Education – June 9, 2010
 Define current surveillance process for CABG
 Develop a Team (IT, Contracted Vendor, Cardiac
Auditors, Leadership, IP&C) to research ability to
electronically export denominator surgical data to
NHSN
 Contracted Cardiac Vendor building a background
program to develop a report off the STS Cardiac
Surgery Database (CSD) for exporting
 Began reporting requirements for pilot project
(numerator data, denominator data export, SCIP
measure data, time & effort measures) – September
1, 2010 for July 2010 data
 Completion – ongoing…Why stop a good process?

25. Sentara’s Experiences
Pit Falls:
Took time to map SH surgical
denominator components (STS CSD) to
NHSN template for export
Time allotment for cardiac abstractors to
review surgical patients
Contracted vendor - Armus
Experience:
Positive
Demonstrated SH’s ability to address
issues of mandatory reporting

26. Building in a Collaborative
Requirement of ARRA funding
Create a project to be flexible and
responsive to acute care IPs’ workload
 Collecting data presentation templates
 Sharing best practices for data feedback
Monthly conference calls
Survey given to IPs and unit-specific
staff to capture the various
perceptions of data utility

27. Data Presentation Survey
 Collect baseline of knowledge regarding data
presentation practices targeted to direct care staff
 Sent to IPs, direct care staff in a selected unit/area
 18 facilities (100%): 17 IPs and 84 staff
 General statements about use of data to lower HAI
rates or impact infection prevention compliance
 Types of staff and their perceived awareness of HAI
data and compliance with infection prevention
practices
 Outcome and process measures staff want to see
and are currently provided
 Types of data and whether they are easy to
understand, useful, and currently presented

28. Data Presentation Survey
Results: IP and Staff
Perceptions
Awareness of HAI data promotes
dialogue among staff and impacts
infection prevention compliance
IPs more likely to think that SSI rates
were improving (65% vs. 48%)
Most respondents thought unit-specific
HAI data were valid and reliable, easy
to understand, timely, and shared at
least quarterly

29. Survey Results (cont’d)
Color coding, comparisons (to average,
benchmark) most useful to staff
Color coding, comparisons, HAI rates,
number of HAIs, and number of days
since last infection were most easy to
understand
SIR – used in some hospitals (20%),
useful (38%), easy to understand (26%)
HAI data most often presented: HH,
CLABSI
Staff want environmental cleaning

30. Survey Results (cont’d)
 Differences in awareness of what data are
presented (IPs vs. staff receiving data)
 Perceived differences in awareness of data
and infection prevention compliance by type of
staff
 Most aware and compliant: nursing leadership, unit
nurses
 Least aware and compliant: physicians
 IPs share data most often with units and
Infection Control Committee
 >75% of respondents present HH, BSIs, SSIs, UTIs,
VAPs
 >75% of respondents present comparison HAI data

31. More infections than predicted (statistically significant)
Observed number of infections similar to predicted
Fewer infections than predicted (statistically significant)
No infections
---SIR = 1.00 when observed = predicted
SSI Pilot SIR by Time Period
0.00 0.50 1.00 1.50 2.00
July-Dec
(H2)
July-Sept
(Q3)
Oct-Dec
(Q4)
SIR and 95% confidence interval

32. SSI Mini-Grant Program
Any activities that support implementation of
the NHSN Procedure-Associated Module,
including but not limited to:
 Equipment and services, such as administrative
and informatics costs
- Example: upgrading or modifying internal systems
 Training and education
- Example: training for staff responsible for collecting and/or
entering surgical site infection surveillance data
 Consultative and technical assistance
- Example: programmer support to help create an electronic
file to upload surgical procedure data directly into NHSN
 Administrative support

33. Awardees
Applications reviewed by VDH and
Virginia Hospital & Healthcare
Association (VHHA)
22 hospitals
Total of ~$290,000
Monies dispersed by July 2011

34. PERSPECTIVES FROM
THE PARTICIPANTS

35. Sentara: A Systems Approach
Total funding: $145,000 for System
Technical assistance (IT) – $124,000
Training [Infection Prevention & Control (IP&C), Data
Auditors] - $21,000
Implementation goals:
Develop and implement an electronic export process
for reporting of surgical procedure data directly into the
NHSN database
Provide training / technical assistance to staff to
facilitate successful implementation of the exporting
process
Create “super users / trainers” who will disseminate the
process throughout the Sentara Healthcare System

36. Sentara: A Systems Approach
Time Line:
Awarded mini-grants - May 2011
Immediately developed Team (IT, Leadership, Finance, IP&C) to
address goals of funding
IT Team began meeting with an action plan based on
components (IT, Training) - June 2011
Hired Consultant to develop IT components from PICIS OR
Manager and “background” data fields - July 2011
Pit Falls:
Other IT priorities (“EPIC Go Live”)
Contracted IT staff
Time line – finances
Experience:
Frustration

37. Next Steps for Sentara
Activity reports (facility-specific) and unused
funding submitted to VDH/VHHA
 November 15, 2011
Implementation of final IT product
 November 2011
Trial use of IT product by IP&C
 December 2011
Validation of process by IP&C
 December 2011 - January 2012
Use of product beginning with Jan 2012
surgical patient population with successful
export of data to NHSN
 February 2012

38. Lessons Learned: Other
Facilities
Electronic medical records are great but
present documentation challenges
Surgeons do not use ICD-9 codes
“Mapping” of required denominator
components time consuming
IT needs “special handling”

39. Resources/Take Home
Messages
Challenge of converting CPT codes to
ICD-9 codes
 Crosswalk soon available!
NHSN forms for Procedure-Associated
Module
 http://www.cdc.gov/nhsn/psc_pa.html
Map entire facility in NHSN – infections
can happen anywhere
Resources to Help Build Business Case
for Electronic Upload (VDH document)
Future training opportunities – APIC-VA
and NHSN

40. Acknowledgments
VDH: Dana Burshell, Carol Jamerson,
Diane Woolard
VHHA: Barbara Brown
APIC-VA
SSI pilot participants
SSI mini-grant recipients

41. The Purpose of Our Work:
“The names of the patients
whose lives we save can never
be known. Our contribution will
be what did not happen to them”
Donald M. Berwick, MD, MPP
Former President and CEO of IHI
Current Administrator of CMS
Andrea.Alvarez@vdh.virginia.gov: 804-864-8097
JPButler@sentara.com: 757-388-3949