2018 NHSN Training – Surgical Site Infection (SSI) Part 2

>> My name is Victoria Russo I’m one of the SSI SMEs here at NHSN I’m going to present this second half of the presentation today and also, we will have some time, hopefully, at the end, for some questions In addition, we do have a table top exercise We were planning on performing today all the different — everybody here is going to be involved and it’s like the table top exercises that were presented yesterday That same concept So and that will probably be about 25 minutes So I’m going to go ahead and start getting through the content here today So welcome back And for those that are web streaming today, just as a reminder, have your chapter 9 and chapter 17 at hand because we’re going to start working through some cases now Okay. So the first thing I want to start off with is highlighting FAQ question number 1 This FAQ addresses what NHSN needs from the user for a complete case review request Those elements, the user must consider when performing SSI surveillance If you are sending NHSN an SSI question, it really helps to provide us with as much details as you can and with complete details This allows us to best guide you when assisting you with a case Now, as we work through the cases today, I want you to go ahead and keep these type of questions in mind because they’re all important here And I want to highlight this because here at NHSN, the SSI team receives questions from users and there are times when we receive questions that there might be some important pieces of information missing and it’s maybe not of your fault, it’s just we want to coach you, want to train you to really, when you’re performing a complete case review, to have these pertinent pieces of information at hand because there will be some back and forth emailing between us and we might be able to wrap your case up quicker for you So what is a superficial incisional SSI? A superficial incisional SSI is an infection that occurs within 30 days after any NHSN operative procedure where day one is the procedure date It involves only the skin and subcutaneous tissues of the incision and the patient has to have at least one of the following criterion met Purulent drainage from the superficial incision, organisms identified from an aseptically-obtained specimen from the superficial incision site, by a culture or non-culture base microbiologic testing method, or C, a superficial incision that is deliberatively opened by a surgeon, attending physician or other designee and culture — or culture — and a culture or non-culture based testing is not performed and the patient has to have at least one of the following symptoms Pain, tenderness, localized swelling, erythema or heat And finally, superficial incisional criteria D is a diagnoses of a superficial incisional SSI by a surgeon or other attending physician or a designee And please note that physician diagnosis is only available in the superficial incisional SSI criteria It does not live in the deep It does not live in the organ space I want to highlight a few of the SSI — superficial SSI reporting instructions here A diagnosis or a treatment of a cellulitis such as redness, warmth, or swelling by itself, does not mean criterion D for superficial incisional SSI But conversely, if there is an incision that is draining or that has organisms identified by a culture or non-culture based testing, this is not considered a cellulitis and you’re going to have to investigate this as an SSI A stitch abscess alone, meaning minimal inflammation and discharge confined to the points of suture penetration, is not considered an SSI You would consider this for potentially meaning a skin or soft tissue infection Also, a localized stab wound or a pin site infection is not considered an SSI You would also consider this for, perhaps, meeting a localized skin or soft tissue infection Please note, that a laparoscopic trocar site for an NHSN operative procedure is not considered a stab wound You would investigate an infection that sets up here as an SSI Remember, that if multiple tissue levels are involved in the infection, the type of SSI reported, whether it be superficial, deep, or organ/space, should reflect the deepest tissue layer involved in the infection during the surveillance period Now this is a screen shot taken from Table 2 of the SSI protocol and this is the table that you would refer to when trying to make the determination as to how long the surveillance period is for a particular NHSN operative procedure There are 39 NHSN operative procedures Some of which are 30-day surveillance period, some of which have a 90-day surveillance period

Remember that superficial incisional SSIs are only followed for 30 days regardless of the procedure type Only 30 days And then secondary incisional SSIs are also only followed for 30 days regardless of the surveillance period of the primary site And these are notes that are — as you can see here — highlighted Okay. So I want to get into what is a superficial incisional secondary infection There are, I believe, seven NSHN operative categories that have a superficial secondary incisional site infection event type that’s allowed to be cited to that particular category A superficial incisional SSI that is identified in a secondary incision in a patient that has had more than one incision would be identified as a SIS And a common example I could give is a patient undergoes coronary artery bypass graft with both donor site and a chest incisions If a patient has an SSI that sets up in the donor site, then you would site this as a superficial incisional secondary SSI Remember though, they’re only followed for 30 days regardless of the surveillance period for the primary site Now, the appendix at the back of SSI chapter 9 does list out all the different operative procedures and which of those operative procedures have secondary sites We’re going to get started on our fourth case On 6/7, a 57-year-old female had an abdominal hysterectomy This was a HYST procedure On 6/12, the patient noted tenderness and purulent drainage from her incision site and is seen in her provider’s office on 6/13 The surgeon removes some staples and inspected the site The surgeon noted the fascia was intact without disruption A culture of the purulent drainage was performed that resulted no growth So you might want to keep this at hand when you’re referring to the questions Might have to refer back to the case Does this case meet criteria for a superficial incisional SSI? Polling is open but these are your options No, the culture was no growth Yes, the patient meets SIP criteria No, the patient meets DIP criteria No, the fascia was intact Okay. I know there’s more clickers out there so I think there was about a hundred I’ll give you a few more seconds Okay. All right Let’s see what — what you thought Okay. Majority wins Um, yes, the patient meets superficial incisional primary criteria Okay. We have another question Which of the superficial incisional primary definitions is met Is it criterion a, b, c, or d? Okay. So you responded with superficial incisional primary criterion a and the majority is correct Let’s see Let’s see the rationale for this Well, first of all, we know that the infection occurred within 30 days after the NHSN operative procedure The infection also involved only skin and subcutaneous tissues of the incision and we have purulent drainage from the superficial incision This does meet And please note that even if — even — because the culture did not grow anything, it doesn’t discount the fact that there was purulence noted there and doesn’t discount the fact that the patient actually meets criteria So you only have to meet one criterion to be able to cite this SSI and one criterion doesn’t cancel out another So NHSN does not define purulent drainage There is no standard clinically agreed upon definition Generally, though, we see a — such elements as thick/viscous, creamy/opaque, fluid discharge with or without blood seen but most of the time we see pus or purulence being noted by a medical professional and this is accepted evidence of purulent drainage We do not accept gram stain results such as WBCs or poly’s to define purulence within the SSI protocol But if you ever have a question about whether a certain descriptor meets purulence, go ahead and email us at NHSN We can take a look at it with you and try to make a determination But like I said, generally, we see purulence pus noted majority of the time Okay. We have another case On 8/31, a 51-year-old male underwent a coronary artery bypass graft times 4

with an endoscopic vein harvesting from his right leg So this is a CBGB procedure On 9/6, he went home On 9/30, the patient had a follow-up appointment with his cardiologist and the MD noted clear yellow drainage from the superficial endoscopic harvest site and they cultured the drainage The sternal incision was noted clean, dry and intact On 10/2, the superficial incision wound culture from that vein harvest site did result positive for staphylococcus epidermidis What would be reported? Is this an SSI? And it’s a superficial incisional primary attributable to the CBGB Is nothing reported here because the infection at the vein harvest site is outside the superficial incisional secondary surveillance period? Or is this an SSI where it’s superficial incisional secondary attributable to the CBGB? Or is there nothing here because the culture resulted with a common skin commensal? Okay. We’re going to close the poll Okay Okay. So I believe you were on the right track but the actual answer to this question is that nothing is reported here due to the fact that the infection at the vein harvest site is outside of the superficial incisional secondary surveillance period Secondary incisional SSIs, like I said, are only followed for a 30-day period regardless of the primary site The fact that a common commensal was isolated had nothing to do with event not meeting This is important because we get questions like this where a user may ask that the event is not accepting in the application I don’t know what I’m doing wrong But sometimes it takes pulling out your calculator or pulling out your calendar, pulling — you know, counting it up by hand It’s important because the date of event can come down to the wire here I didn’t really mean to trick you but it’s a valid question and these are — these are realistic cases So just keep many mind that yes, if the patient had a date of event within the appropriate surveillance period, that we would cite this but because it was outside of the 30-day surveillance period, this we could not site as a superficial incisional secondary SSI And in fact, the application is smart enough that if you go in and try to enter this event, you’re going to get an alert screen and that might — that’s going to trigger you to question, you know, well, what’s going on here and it comes down to, really, the date of event There are business rules that are built in the application that are smart enough to detect this Okay. So now let’s get going and review deep incisional SSI So a deep incisional SSI can occur within 30 or 90 days from the NHSN operative procedure date where day one is the procedure date It involves the deep soft tissues of the incision So for example, the fascial and muscle layers And the patient has to meet at least one of the following Purulent drainage from the deep incision, a; b, would be — there’s three parts to b. So b, you must meet all three parts A deep incision that spontaneously dehisces or is deliberatively opened or aspirated by the surgeon, physician or other designee; a culture is collected from the deep tissue or no culture is collected And the patient has to have at least one sign or symptom such as fever, localized pain or tenderness If they do culture the deep tissue level and it’s negative, automatically, you cannot meet criterion b. Finally, criterion c is an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathological exam or imaging test But I wanted to hone in on criterion b. We actually — we didn’t update the criteria this year We just tweaked the formatting a little bit to, hopefully, read better because sometimes users would get turned around as far as what goes with what, can I meet this? Does it meet that? Does it go with a? Does it go with b? But for b, you must meet these three criteria And I’m not going to dwell on this but like superficial incisional SSIs, deep incisional SSIs also have the option of a deep incisional primary and a deep incisional secondary incision event code I explained what this was The same rules apply You can’t follow beyond 30 days for the deep incisional secondary site Okay. We have another case On 4/15, we have a 67-year-old male that underwent a right HPRO due to severe end-stage osteoarthritis On 4/18, the patient was discharged On 5/13, the patient presented to the ED due to traumatic wound dehiscence

after a fall while walking his dog The patient was noted with new pain at his incision site after the fall On 5/14, due to this dehiscence, the patient returned to the OR for a washout and reclosure what the surgeon noted as a fascial dehiscence but there was no evidence of infection seen and no cultures were collected Is this an SSI? Remember to have your criteria in front of you And do your best I mean, make your best guess here based on the criteria and what you think Okay. So let’s see which — the answer is Okay. All right So the answer is no This is not an SSI And let’s talk about why Why not. Okay So first of all, we know that the event would fall within the appropriate surveillance period So that is met Then we go along and we know that this doesn’t involve the deep tissues of the infection So that is met And now we meet one of the — one of the actual criterion and we’re honing in on deep and this is not met because even though the patient had a dehiscence, this is not a mechanical — this is not a spontaneous dehiscence This is a mechanical dehiscence because the patient dehisced due to falling You know, just didn’t spontaneous dehisce on its own So — and there was new pain due to the fall This seems a little tricky but these are — this is — these are questions that we do receive You know, there’s a difference between a spontaneous dehiscence and a mechanical dehiscence Okay. So we have one more case here On 2/27, we have a 39-year-old male that underwent a right COLO procedure On 3/7, the patient reported abdominal incision pain and had a recorded temp of 37.7 On 3/10, the patient returned to the OR where the incision was reopened down into the deep tissue level Although purulence was not seen, cultures were collected from both the superficial and the deep tissue levels On 3/13, these cultures resulted with Candida albicans What infection should be reported? Is it a superficial incisional primary, a deep incisional primary, the organ/space IAB, or is there no SSI here? Okay. I’m going to stop the poll I know some of you are still working I’m sorry Yes. Yes. Deep incisional primary You are correct Oh, okay. You have your — you have your criteria still in front of you so which of these criterion is met? We know it meets Which one meets? A, B, or C? Give you a coup — a second here Okay. And the correct answer is b The infection occurred within the appropriate surveillance period and involved the deep soft tissues and we know that there was a deliberate opening or aspiration by the surgeon An organism was collected from the deep tissue level and was positive — or a culture was collected was positive for organism So the deep tissue level And the patient was also noted with localized pain The type of SSI reported, as you remember, must reflect the deepest tissue layer involved in the infection during the surveillance period Since both, technically, superficial incisional primary and deep incisional primary are met, we report the deep incisional primary infection The deepest tissue level involved in the — in the infection during the surveillance period Great job Okay. And finally, organ space SSI My favorite Okay. So what is the definition of an organ space SSI Well, the infection can occur within 30 or 90 days after an NHSN operative procedure where day one is the procedure date It involves any part of the body that’s deeper than the facial muscle layers that is opened or manipulated during the operative procedure, and the patient has to meet at least one of the following Purulent drainage from a drain that is placed into the organ/space So for an example, a closed suction drainage system, an open drain, a T-tube drain,

CT guided drainage, perhaps; or B, organisms are identified from an aseptically obtained fluid or tissue in the organ/space by a culture or non-culture based microbiologic testing method; or C, an abscess or other evidence of an infection involving the organ/space detected on gross anatomic or histopath or imaging test evidence suggestive of infection But wait. You must also meet one more definition You must also meet at least one criterion for a specific organ/space infection site listed in Table 3 And the definitions are within table — or within chapter 17 And we’ll talk about this But again, to meet organ/space criteria, you have to meet general organ/space definition from chapter 9 and you also have to meet the site-specific definition from chapter 17 There’s two parts to this And this is what I’m talking about here Table 3 in the SSI protocol lists the specific sites that are eligible for organ/space SSI attribution They’re listed here Okay? And you must meet the actual definition, completely, to cite an organ/space SSI The appendix at the back of chapter 9 is a wonderful tool and it lists the specific event codes that can apply to the procedure codes So for example, if a patient undergoes an APPY procedure, and they develop an SSI, you could refer to this and to determine what type of SSI you could report, whether it’s a superficial incisional primary, a deep incisional primary, an organ/space GIT or an organ/space IAB So it’s — it’s a nice tool, here, to be able to refer to And again, when you are performing SSI surveillance for organ/space SSI, you must meet criteria for both — from both the general organ/space definition, as well as the site specific So what I was talking about, chapter 17 And this is important, especially when you’re actually entering this within the application of the event because you want to make sure that all the important elements are included, otherwise the event may not accept You want to be complete here Okay. So we’re going to move now into a couple SSI event reporting instructions We get questions here and there regarding evasive manipulation or accession of the operative site The guidance regarding invasive manipulation/accession is that an SSI will not be attributed if the following three criteria are all met During the post-op period, the surgical site is without evidence of infection And then an invasive manipulation or accession of the site is performed for a diagnostic or therapeutic purposes And then an infection subsequently develops in a tissue level which was entered during the manipulation accession Two of the most common types of manipulation or accessions that I could give examples are, patients with shunts and they have their shunts access for obtaining CSF And then after these accessions, then the patient develops an infection And also another common example would be breast expanders Fluids placed into the expander — in the provider office — and this can be a risk every time they do that for the patient developing infection Tissue levels that are below the deepest entered level during this accession or manipulation will still be eligible for SSI For example, if there’s a superficial debridement following a COLO procedure where the muscle fascia and the organ/space was not entered during the debridement, a subsequent organ/space SSI following the debridement may be an SSI attributable back to the index COLO procedure Now this reporting instruction does not apply to closed manipulation, for example, a closed reduction of a dislocated hip after an orthopedic procedure And also, invasive manipulation does not include wound packing or changing of wound packing materials as part of the routine post-op care Changing — a wound vac change These are all standard post operative, you know, this is post-op care These are not deemed invasive manipulation So just recognize that that — these forms of post-op care are not invasive manipulation Okay. So the next reporting instruction relates to SSI attribution to an NHSN operative procedure when several are performed on different dates because we see this We see where we have patients that are going to like — it’s almost serial going to the OR You know, they’re in the hospital They’re very sick and they’re going back and forth to the OR for different operative procedures So if the patient has several NHSN operative procedures performed on different dates prior to an infection and then they end up developing an SSI at some point, as far as attribution, you want to attribute the SSI to the operative procedure that was performed most closely in time prior to the infection date, unless there was evidence

that the SSI should be attributed to another procedure And let me give you an example of this If a patient underwent a COLO on 10/2, two weeks later on 10/18, he returned to the OR for now an XLAP via the same incision He developed an incisional SSI on 10/30 So the SSI is attributed to the second procedure, the XLAP and not the COLO because the XLAP was most recent in time And what is a surveillance period? An SSI surveillance period? This is a frequently asked question Each return trip to the OR via the same site ends the surveillance period from prior infection and resets the new surveillance period SSIs are normally attributed the most recent trip to the OR There is no such thing in SSI surveillance such as, you know, POA ongoing You know, the patient goes to the OR for an NHSN operative procedure, you begin a new surveillance period where you start to — you monitor for an SSI That’s an opportunity They go into the OR Now we’re going to monitor for an SSI You can’t just say that, oh, no You know, that infection was an ongoing infection that never quite cleared up, but for NHSN purposes, they’re going to the OR and the surveillance period does begin where you’d monitor for an SSI And so this is another question that we get from time to time, regarding attribution when there’s multiple procedures being performed during the same trip to the OR and the patient develops an SSI and how do we — what procedure do we give that SSI to? So when there are multiple types of NHSN operative procedures performed during a single trip to the OR and the patient develops an SSI, you want to first attempt to determine the procedure that is thought to be associated with the infection You know, through chart review and trying to make that determination And if it’s not clear — and we see this often with superficial incisional SSIs — we have a table in the SSI protocol, it’s Table 4, and it’s the NHSN Principal Operative Procedure Selection List table And from here, you would determine which procedure to attribute the SSI to Those NHSN operative procedures with the highest risk of SSI are listed before those with lower risk of SSI in this table So it’s a tool there to guide you and to help you if you’re just having trouble trying to determine where the attribution should go And this is an example A patient has both a COLO procedure and a HYST procedure via the same incision site And within 30 days, the patient developed purulent drainage at the incision site Documentation stated that the muscle fascia and the organ/space tissue layers were intact The patient met criteria for a superficial incisional SSI attributable to the COLO procedure because it was — it was unclear which procedure to deep — to attribute the SSI to so when referring to the Table 4, here, you can see that COLO is above HYST so that’s the procedure you would attribute the SSI to Okay. Okay Let’s move on to the next slide here This is case 8 So we have, I believe, 11 cases in this presentation So — on 7/9, a patient was admitted and underwent a laparoscopic hysterectomy, a HYST procedure with a wound class of 2 On 7/11, the patient did well and was discharged home On 7/20, the patient was readmitted with abdominal tenderness And a CT of the abdomen/pelvis revealed a large fluid collection CT-guided drainage was performed of this pelvic fluid collection that revealed 75cc’s of purulent material Does this patient meet criteria for an organ/space SSI? And the poll — okay The poll is open now Remember, the question is, does this patient meet criteria for an organ/space SSI? Okay? I’m going to close the poll and see what you — let’s see what you all think And the answer is yes The patient does meet criteria for an organ/spaced SSI We know the infection occurred within 30 days of the operative procedure category It involved the organ/space and there was evidence of infection seen on gross anatomic exam and we also had imaging test evidence to suggest of infection This is enough to meet general organ/space criteria and move on to see whether site specific criteria can be met So knowing the details of the case, what site specific SSI does this patient have? Is this a deep incisional primary? Is this an intraabdominal infection? Is this an OREP infection? Is this is GIT infection? And look back at the case and read exactly where that infection seems — is setting up

Okay Okay. This is all good This is why we’re here Okay. So the actual answer to the question is, this is an organ/space SSI OREP Let’s talk about that Because OREP is the definition designated to those deep pelvic tissue infections or other infections of the male or female reproductive tract But infections that are localized to the deep pelvic space, you would apply OREP This meets OREP criterion 2 The patient has an abscess or other evidence of infection on gross anatomic exam The patient has a purulence noted within the pelvis Why isn’t this considered an IAB? Well, because IAB involves the general intraabdominal space, not specified elsewhere such as gallbladder, bile ducts, liver, spleen, pancreas, peritoneum, retroperitoneal, subphrenic or subdiaphragmatic space or other intraabdominal tissue or area not specified elsewhere The general intraabdominal space Why isn’t this a GIT? Because GIT involves infections localized within the lumen of the GI tract Okay. And I’m glad that I brought that up because we get questions about this sometimes and there’s confusion surrounding where to attribute the SSI And it’s not always black and white because sometimes infection crosses — it’s within multiple spaces But this was clearly noted as a localized deep pelvic tissue infection and in those cases, you attribute the SSI as an OREP Okay. We have the same question but a little bit of a different scenario On 7/9, a patient was admitted and underwent a laparoscopic hysterectomy procedure While in recovery, the patient’s vitals declined Within two hours of the finish of the HYST procedure, the patient went back to the OR for an exploratory laparotomy, an XLAP, through the previous HYST incision site XLAP findings revealed an excessive bleed Now on 7/16, the patient ended up, you know, doing well and then was discharged home On 7/20, the patient was readmitted though with abdominal tenderness and a CT of the abdomen pelvis revealed a large pelvic fluid collection CT guided drainage of the pelvic fluid collection revealed 75cc’s of purulent material What should be reported here? Is this an SSI OREP attributed to the 7/9 HYST? Is this an SSI OREP attributed to the 7/9 XLAP? Is there no SSI here because the XLAP was an invasive manipulation? These are some of the reporting instructions and definitions that we covered earlier in the presentation We’re just — we want to apply them now and see how that goes Okay I know it’s tough because we want to, like, you know, take more time with this and — but in the interest of time, I’m going to have to close the poll out and let’s just talk about it I’m very proud of you This is an OREP attributed to the 7/9 HYST procedure And the rationale behind this is, that you apply the 24-hour rule here We know this is an SSI This is an OREP, but the question comes down to, how do we attribute this SSI on this infection And you do not apply the invasive manipulation guidance here because — Jennifer covered this earlier on in the presentation — but this is a situation where you would apply the 24-hour rule The patient actually ended up going back to the OR, within 24 hours of the finish time of the HYST procedure for an XLAP procedure so, therefore, you’d have one denominator for procedure form and that would be for the HYST procedure Okay? And then you would not include XLAP within your denominator data and you follow the 24-hour rule reporting instructions for designation of wound class, ASA, and surgical wound closure technique So this is an SSI OREP attributable to the HYST procedure This is the 24-hour rule in action So. This is — this is very realistic These are cases we receive These are questions and cases that you come across Okay. So now I want to review the definition of gross anatomic exam Gross anatomical exam This can be found in key terms We get questions about this sometimes, especially as it relates to the organ/space criteria

What is a gross anatomical exam? Well, this — there has to be evidence of infection elicited or visualized on physical examination or observed during an invasive procedure This includes physical examination of a patient during admission or subsequent assessments of the patient and may include findings noted during a medical or invasive procedure dependent on the location of an infection, as well as the NHSN infection criteria So what does that mean? Let me give you some examples of what this means This could be an example of an intraabdominal abscess that actually required an invasive procedure to actually visualize the abscess Perhaps they went back into the OR or they — some sort of invasive procedure occurred and they actually saw that there was an intraabdominal abscess Perhaps, maybe, there’s visualization of pus or purulent drainage from a drain within an abscess Like a good example of this would be CT guided drainage And there’s a CT guided drainage performed, they’re seeing purulent material coming out, this is gross anatomic exam You’re seeing this purulence come out And then also relating — abdominal pain elicited on physical exam post CSEC or hysterectomy only is sufficient evidence of infection detected without an invasive procedure of the general organ/space SSI criteria Because we see that sometimes these patients don’t return to OR for visualization of infection following these procedures but we want to make sure it’s enough to meet the general before you move on to meet site specific because we don’t want to lose out on capturing those SSI events But please note that imaging test evidence cannot be applied to meet gross anatomic evidence of infection I get questions weekly about this Well, I saw that they said there was an abscess noted on the CT or, you know, on the imaging, so therefore, this patient meets organ/space SSI criteria and site specific IAB, right? Well, no, because that’s an imaging test It might be enough to meet general organ/space and move on, but you’re going to have to have more information there to back up because imaging, as we know, is not always definitive Fluid collection versus abscess versus seroma So please note that imaging test evidence is not the same as gross anatomic evidence of infection Okay. Case 9 You warmed up here On 10/5, we have a 76-year-old underwent a CARD procedure On 10/18, while home, the patient began to cough excessively and complained of pain at the sternal incision site The patient was readmitted On 10/19, the surgeon noted that the distal end of the sternal wound had spontaneously dehisced down to the level of the sternum No cultures were performed On 10/20, the patient went to the OR for debridement of the sternum And this was a non-HNSN operative procedure The surgeon performed debridement down into the sternal bone due to necrosis but there was no evidence of purulence that was noted No cultures were performed here either On 10/24, the patient was noted with purulent drainage from a sternal incision and returned to the OR for repeat I & D. Two cultures were collected of the sternal bone and both subsequently returned positive for MRSA Is there an SSI attributed to the CARD procedure here? And you know, as you’re working — as you’re looking at this, think about the patient went to the OR more than once, right? Okay. So let’s see what the answer is Well, that’s okay This was — there’s multiple moving parts here and we’re going to talk about it because this is a realistic case This is actually a deep incisional primary SSI that meets criterion B. And let’s talk about it Well, we know that it occurs within the appropriate surveillance period for a deep incisional The deep tissues are involved And you remember that the incision was noted as spontaneously dehiscing There was no culture collected and the patient had localized pain or tenderness A dehiscence of the deep tissues occurred to the level of the sternum — occurring to the level of the sternum, this meeting — this is the deep tissue level Okay, now look back What is the date of event then? We know this is a deep incisional SSI Then what would be the date of event here? Think about your elements First element used to meet the SSI criterion What was the date of event? Okay. So the date of — the date of event

for your deep incisional SSI is what we’re looking for here Okay. So the answer is October 18th and that is because the first element used to meet criteria is met because the patient had localized pain Okay. And so the big question is why doesn’t this meet organ/space SSI? Obviously, there was something going on in the bones, you know, this went down to the organ/space Well, invasive manipulation of the organ/space tissue level occurred during the 10/20 non-NHSN operative procedure You know, that’s — they’re taking that patient back to the OR They’re now manipulating the organ/space site This invasive manipulation now ended the surveillance period for 10/5 CARD It’s — you can’t continue to monitor for an SSI to attribute back to the CARD because you’ve gone into that space now, again, for another operative procedure The bone infection on 10/24, which we acknowledge there’s a bone infection here, but it cannot be attributed as an SSI back to the CARD procedure And this is important because there was a procedure that occurred, here, and it was a non-NHSN operative procedure and that — you know, that cut off your surveillance period for the CARD And non-NHSN operative procedures, we don’t perform SSI surveillance for That’s why you always want to determine the ICD-10 or CPT code assigned to the procedure to determine if it qualified for surveillance You’ll email NHSN, you’ll ask us, well, I have this, this and this and this Does this meet SSI? I’m looking and I’m thinking, I don’t know if that meets an — I don’t know if that’s an NHSN operative procedure so you want to first and foremost go and check and just make sure that that code maps by using the documents that we provide to an NHSN operative procedure And again, you cannot apply SSI criteria to a non-NHSN operative procedure We don’t endorse it There’s also — there’s no surveillance periods that are set up for that We don’t have designated definitions to state that you can apply to especially with the organ/space So hopefully that was helpful, but I think it’s important to consider this because it’s not always cut and dry and there’s sometimes curveballs thrown that we have to then continue to think about how we want to approach the infection I want to note that I’m not going to go through all this but we have an FAQ document noted on the — in our FAQ document, we have a question regarding level of infection after a sternal — of a sternal site after cardiac procedures This is just helpful because we do get questions about this and it might be helpful for you to refer to if you’re ever getting stumped Okay. So we have two more cases So hang in there Case 10. On 2/11, we have a 71-year-old patient that underwent a right HPRO On 2/26, the patient presented to the MD office with hip pain and a temp of 37.9 The superficial incision was noted with purulent drainage The patient was readmitted to the hospital On 2/27, the patient now returned to the OR where the wound was probed and a small 1 centimeter gap was noted along the subcutaneous tissues where purulent material tracked laterally down to the level of the prosthesis Okay. So we know this is an SSI, but what type of SSI Is this a superficial incisional primary that we report? Do we report this as a deep incisional primary, or is there something going on in the organ/space level Is this an organ/space SSI? Okay. So I’m just going to go ahead and close the poll out Great job Organ/space SSI Okay. So which site specific organ/space definition should be reviewed for this case? We know that it’s — we’re looking at organ/space but which of the definitions from chapter 17 following this procedure do we want to hone in on? PJI, a periprosthetic joint infection or joint infection? Okay. Great job Periprosthetic joint infection Because PJI can only be used following an HPRO or KPRO You wouldn’t refer to — you wouldn’t report a joint If you try to enter the joint into the application, it’s going to spit it out and say that this doesn’t make sense So if you have an HPRO or KPRO and develop a organ/space SSI following that procedure type, you would refer to PJI here and not joint Also, bone is an option following an HPRO or KPRO but in this case, we — it’s a teaching point because people try to apply joint

And what is the date of event for this organ/space SSI? Okay. The polling is still closed but I’m hoping it’ll open soon There we go So if you try to vote — if you voted, try voting one more time because it was closed in the beginning Okay No [ Laughter ] It’s okay That’s okay Well, the date of event for this organ/space SSI is February 27th because that’s the date that we noted that there was something going on within the organ/space that meets criteria And we’ll talk about what that is So we know that this is an organ/space because it falls within the appropriate surveillance period in the organ/space level We have other evidence of infection that we see on gross anatomic exam What do we think that other evidence of infection is? We meet it We have a sinus tract The fact that there was a notation of a track starting at the superficial tissue level terminating into the joint space where there’s purulence noted all the way down, this is — this definitely sounds like a sinus tract So that would be the answer to the question So this is a sinus tract communicating with the joint This is a PJI The patient met criteria for organ/space PJI on February 27th and then, you, of course, report the SSI at the deepest tissue level involved in the infection We know that there was purulence at the superficial incisional level Right? But because of the reporting instruction, we don’t report both We report one and at the deepest tissue level, which would be the organ/space Great job Our last case of the presentation Okay. On 11/23, we have a 59-year-old female that was admitted for sudden onset of severe abdominal pain A COLO was performed that revealed purulent material in the intraabdominal space On 12/11, the patient was readmitted to the hospital with new abdominal pain and nausea Blood cultures were obtained A CT of the abdomen revealed a small fluid collection in the right lower quadrant that was too small to drain The attending physician documented antimicrobial treatment for an intraabdominal infection On 12/13, the blood cultures came back positive for B. fragilis So you have your resource manuals It’s kind of a loaded question here, but does this patient meet the criteria for an SSI? And I will hint you into towards looking at one of the organ/space criteria Think about what the physician was noting and the evidence that you had there I’m going to give you another minute on this one It’s our last question We’re doing okay on time So Okay. I’m going to have to close the poll

I’m sorry Great job Great job I know we’re — we’re doing these cases in a short amount of time so it’s hard to be able to sit down and kind of like look at everything, but you’re correct This is an SSI It’s an organ/space IAB and there is a secondary BSI here Okay. So think back at the original question asked Look back at the original question, original case Does this patient meet the criteria for PATOS? So we now know that we have an SSI, here, but now we have to answer the question, PATOS equals yes or no Is PATOS yes or is PATOS no? Okay. Okay Let’s see Yea. Great job PATOS equals yes because why? An abscess was noted at the organ/space level at the time of the initial procedure And you ended up developing an organ/space SSI So again, this meets criteria because it occurred within the appropriate surveillance period, involved the organ/space and we have imaging test evidence suggestive of an infection We move on to meet — to look at site specific and we look at IAB 3b Is that where everybody was looking? 3b? So we know we have two symptoms noted We have nausea and we have abdominal pain We also have an organism identified from the blood and the organism is an MBI organism So that’s eligible to meet the criteria And then also, we have that imaging test that is supported by clinical correlation that physician documented antimicrobial treatment for an intraabdominal infection So great job and this meets Okay. So it meets and you indicate PATOS equals yes What is clinical correlation? This is taken from key terms and this means that the physician documents antimicrobial treatment for a site specific infection And we know we have an MBI organism that was isolated in the blood and I’m — I know that Kathy reviewed some of this yesterday and this will be reviewed again later within the week, but I just wanted to briefly touch on the fact that if you aren’t sure whether an organism is an MBI organism or not, the BSI protocol does have an appendix that has a condensed list of these but then also has a link to the full list But also, the SSI supporting materials section does have a link to the NHSN organism list where you can find all of the MBI organisms for 2018 And just pay attention to what year you’re performing surveillance for because there might be new pathogens that are listed on this list and maybe not the year prior So pay attention to that and go to the right supporting materials document Okay. So that wrapped up the cases for the presentation Great job I know. It’s a condensed — you know, we don’t have a lot of time to sit and chunk through the criteria but I think you all did a really good job and I wanted to circle back to the fact that this — this slide again I know that I already talked about it but I want to bring it up again and I hope that, now, it hopes to realize as we work through some of the cases, why this information is so important when you’re — you’re looking at SSI surveillance These are all critical pieces of information that you’re going to want to hone in on when performing surveillance, especially while — also when emailing NHSN These are important details that you don’t want to leave out Okay. So I had this in here last year and I decided to keep it in here this year because who doesn’t like dogs This is just a cute little picture and we can all take a breath here before we move on So to completing the SSI event form Okay. All right I’m so sorry I have to move on [sigh] I know All right So when you are — and Jennifer touched on this a little bit when she was talking about the event form and the denominator for procedure form, but I wanted to talk a little bit more specifically about the SSI event form And by a show of hands, how many of you in the room actually physically fill out the SSI event form still? Okay. So some of you still

I mean, it’s an excellent tool It captures all the information that’s needed to be entered into the application You want to complete a surgical site infection SSI event form for each patient found to have an SSI using the definitions And there is a table of instructions document, which is — Jennifer had mentioned on the SSI web page, that actually goes into each field here and talks about what it means So for example, like what is an NHSN operative procedure code? Or date of event How do you assign that? So. Let’s talk about patient demographic information What’s highlighted here in yellow is required The Medicare number is required for events Only being followed for CMS reporting So SSI COLO or those COLO and HYST procedures And here you can see that the date admitted to the facility I wanted to highlight because sometimes we get questions asking would that — what date is that? What date does that pertain to? Readmission? The actual index operative procedure admission? But the date admitted to the facility is the date the patient was admitted to the hospital when the operation was performed not the date of readmission for example Also here, location — note that location and ICD-10, CPT code fields are optional fields Those aren’t required fields but you’re going to want to know your ICD-10 or CPT codes to be able to determine whether a procedure is an NHSN operative procedure but you don’t necessarily have to include the code in the application And when you’re filling out the event details, you’re going to want to indicate what type of organ/space SSI is it again because again, we have to make a determination what it is So for here, this is a PJI and don’t forget, the PATOS field, which is a required field And it only has to do with the event form It has nothing to do with the denominator for procedure form We get questions sometimes about that Well, we have a patient that was admitted and so this is PATOS so we don’t worry about it, right? I’m like, no, I mean, maybe they’re admitted and they have an operative procedure where there’s infection noted but that starts the surveillance period So if the patient ends up developing an SSI in that surveillance period, that’s when you actually go back and then determine if PATOS equals yes or no And then, again, these are the different specific elements that you’ll want to check, you know, just make sure that you check all the elements that pertain to the SSI event on the event details section Don’t miss anything and just pay attention to that, what would be — what would be needed to be included This, here, is the — basically, it’s required that you let NHSN know how you detected that SSI It’s a required box So you could either detect the SSI by — during admission, during post discharge surveillance, readmission to the facility where the procedure was performed or readmission to the facility other than where the procedure was performed So. Here, you can see additional required fields are provided If a patient died, you are required to answer this, if the SSI contributed to death, IP shouldn’t just be making that call You’re going to want to make sure that that’s documented and there’s evidence there and — for example of death or a discharge note or an autopsy report Okay. Let’s talk about linking procedures You can’t link an SSI event to a procedure if the procedure is not in the application So first thing you want to do is you want to make sure that the procedure is in the application Then you want to enter your SSI event And then link the two records So the data speaks to each You want to make sure that the numerator and denominator are both in the application This is just a visual about an example of how it looks in the application I’m sure you’re all familiar with this When you want to link to a procedure, you click this button And then your options come up And as you can see, here, this — you check the box next to the appropriate procedure and you click to choose January 7, 2018, is where the procedure is where I’m linking this SSI event to After linking, after the application recognizes that the actual denominator is in the application, you want to then continue to fill out the remaining pertinent pieces of information before you actually save the record for everything to be final There you go And you hit save And if you were on the NHSN patient safety component home page and you see alerts that are there for a reason, they’re there for a reason I mean, you’ve got to pay attention to these alerts and address them, otherwise your data will be incomplete and not included in analysis So this is just an example that there is a lot of incomplete procedures,

a lot of missing procedures and a lot of missing procedure associative events Don’t just keep clicking away, and clicking out of it Know that those are there for a reason to address I wanted to just briefly mention that NHSN publishes quarterly AJIC case studies in American Journal of Infection Control and if you haven’t already taken advantage of these, please do They’re really great — great case studies and they’re very realistic and they’re nice to do either by yourself as a single practitioner or even get together with your peers to compare and to work through cases together So that concludes the actual presentation We will have a couple minutes for questions and then we are going to go ahead and we have a table top exercise that we will start in a few minutes where we’re going to take probably about 15 minutes or so to let you work amongst yourselves with your tables and then we’re going to call up some volunteers to actually let us know what your determinations are So thank you so much, today, for your attention This was a long presentation, I know A lot of material is packed into this, but please note that, you know, this material, hopefully, will help you with performing your SSI surveillance and if you have any additional questions, we’re here to be able to assist And we can’t assist with any case questions because we don’t have all the material in front of us and it’s easiest if we — you email us those separately So is there any burning questions that anyone has right now before we start our case table top studies? >> I have one >> Oh >> Okay. Vicki we will start with a question from the web streamers while people are making their way in the room to a mic So the first question is, I know that a superficial surgical site infection is reported to NHSN and not included in CMS reporting, but is this true for all surgical procedure categories? >> Yep. So you’re going to want to When you perform SSI surveillance, you’re agreeing to — and you indicate that in your monthly reporting plan, you’re agreeing to perform that surveillance completely You’re not just going to leave out certain tissue levels of SSI events So although we don’t furnish on the deep and organ/space SSI PATOS events to CMS, those are still required to be reported to us at NHSN We still capture that information and collect that information >> My question is regarding PATOS If you discover a SSI and the procedure met the PATOS criteria, you report the event, but do you remove the procedure from your denominator or do you leave it in your denominator? >> That’s a really good question So with PATOS, if you identify an SSI following an NHSN operative procedure, you go back to the index operative procedure to determine PATOS You indicate PATOS equals yes So you don’t remove anything Everything gets furnished onto NHSN NHSN will make a determination, for example, if it’s a CMS COLO or HYST, we will not push those deep and organ/space onto CMS Everything must get reported to us Don’t remove anything because we need to see the denominators We need to see the numerators >> Thank you >> You’re welcome >> Um, can you clarify when a washout is done with the wound during a vac change? Is that considered manipulation since the wound vacs are not considered manipulation — invasive manipulation? >> I would need to see specifics of the case I mean, in general, we don’t consider wound vac like changes or wound vacs as a form of invasive manipulation But sometimes there could be more elements or there could be more going on with the case So perhaps maybe take the patient back to the OR They’re maybe going a little bit in and doing an I&D, then that may be an invasive manipulation but we’d need to really see all the elements to be able to help with that determination So in general, a wound vac is not considered an invasive manipulation but there could be more to the case where we would need to investigate further >> Okay. I also have another question If you use surveys to do some of your surveillance on SSIs, how do you incorporate that information into your record for validation purposes later on? [ Inaudible ] Does that make sense what I’m asking? >> So are you — like survey — so we’d want to make sure that the information is captured within the appropriate like quarter >> Right >> So if you find information that comes back at a later date where the data’s already been submitted, then that data’s been submitted >> No. I mean if you have like a survey as part of what’s helping meet the criteria for an SSI

but it’s a survey that you’ve gotten back from a provider’s office, do you include that as part of your EMR? Do you have that scanned into your record so that during validation, that information goes? >> CMS actually doesn’t validate cases that are detected out by post discharge surveillance but you can scan that into your EMR or keep it in your IP records in your office just so if you get a state validation, you can show them that you are doing that sort of surveillance >> Okay. Thank you >> VP shunts for diagnosis purposes, if it’s not documented, I have to count it as an infection, right? SSI? For shunts >> So ventricular — a ventricular shunt? >> Correct >> If that’s a procedure that you’re following within your monthly reporting plan and — >> Correct >> And an SSI develops, then you would site the SSI back to the [inaudible] >> So the shunt was accessed and it’s not documented as — for diagnosis purposes So do you count it as an infection, right? If it’s not documented >> I mean, it depends on the details of the case, really But I mean, in general, access of a ventricular — access of a shunt could be a form of an invasive manipulation But I’d need to see the details of the case if you’re trying to figure out whether or not to attribute that as an SSI >> Okay. Thanks >> What do you do if you have a contradictory diagnosis preop on a return? They’re saying that it’s a superficial surgical site of infection They get in there, they go into the deeper levels and say it’s seroma >> Okay. So like before they get the patient to the OR they’re saying this and then they get in there and it’s something else? >> Right. So which diagnosis do you go with? >> So are you referring to the superficial incisional criteria? >> Whenever it doesn’t meet that fully because there was purulent drainage but, you know, they said it was — superficial >> Um-hmm >> But then post-op, they’re saying there’s — it’s a seroma, it goes into the fascia layer so it doesn’t meet superficial anything now because we’re deeper But it doesn’t meet that because negative culture or the diagnosis changed >> Sure. Well, the fact that there was purulence noted it will meet criteria Just because they may follow up at a, you know, that day or later within the admission and actually then diagnose the patient not having an infection or state that there was no purulence noted, one criterion — it doesn’t supersede the first There was documentation by a medical professional there, we take that documentation >> Okay. So just go with if there’s any documentation to meet criteria then it meets that criteria >> Yes >> Okay >> Yes. Yes >> All right >> All right We have another question from the web streamers It says, in SSI event determination, can the same element be used twice to meet criteria and specifically, they’re asking about meeting organ/space SSI criteria general and a specific organ/space infection criteria >> The answer to that is yes If you have an element that you use to meet your general organ/space say a positive culture from the site, you can also use that same positive culture to meet one of the elements of your site specific criterion to meet the whole organ/space SSI definition >> And it’s all — it’s not uncommon to see that It’s not uncommon that like, maybe, an abscess seen on reoperation can be both site specific and organ specific >> Just some clarification on superficial on secondary So if a culture is done before the 30 days but it did not result until after the 30 days, it is not — >> It’s the culture date So the fact that the culture would have been collected on say — >> So if the result date >> No >> Or the collection day, which one? >> Yeah. It’s the collection date I’m sorry It’s the collection date >> Because I get — okay So going back to that question >> Even if it finalized a few days later >> Because on 9/30, the culture date — unless I’m not reading this right after reading so much >> I made sure to count, I swear, with my hands This was — >> On 9/30 and that was before — and that was within 30 days unless I’m miscounting >> 31 days >> Well maybe — I didn’t have my calendar out >> It really comes down to the wire sometimes You know, I have to keep counting — >> I counted 30 but, you know, because that’s why I got so confused on that because it looked like on 10/2 was the result date and we’ve always gone by the collection date but I thought 9/30 was 30 days but I guess I miscounted

>> It was tricky I’m sorry I’m sorry But yes >> Sorry. We did that on purpose >> Okay. From the web streamers Returning — regarding a return to the OR in the 24-hour rule So the first procedure is a non-NHSN operative procedure and then they return within 24 hours for an NHSN operative procedure Is any procedure reported at that point? >> That’s a very good question And we do see this from time to time If there is a non-NHSN operative procedure performed and then within 24 hours of the finish time of that non-NHSN operative procedure, through the same incision site, they go back and they perform an NHSN operative procedure, you do not include within your denominator data that second procedure because it can go both ways It basically was folded in to if first procedure Hence, you don’t have a denominator for procedure form Okay. So I think this, in the interest of time and I don’t want to rush you through this, we’re going to go ahead and get started with our table top At every table, there is — I believe there are — there are these — there’s about two pages front and back and they’re Power Points with questions and they’re numbered one, two, three, and four, the pages, with questions below And basically what this is, it’s a progressive case So it’s one patient that is going in and out of the OR and there’s a lot going on with this patient So go ahead and, amongst yourselves, you know, our hope is that maybe you could talk about this with each other and come up with a determination We’ll give you about 15 minutes or so and then we — 15 minutes, 20 minutes, and then we will then reconvene and kind of walk through what the responses are >> How’s everybody doing? Are you about ready to start answering or do you need a couple more minutes You good? Is everybody good? Can I see a show of hands? People feel pretty ready? Okay. We’ll get to answering the questions The quicker we get through this the earlier you guys can go to lunch >> So is everybody ready to start? So we have randomly assigned tables to questions When I say random, it was just kind of like the luck of the draw if you’re sitting at the right table All right So Vicki roll it Here’s the question >> Okay. On 1/5, we have a 45-year-old woman that undergoes an abdominal hysterectomy On 1/12, at her post-op follow-up visit, the surgeon notes purulence from the surgical incision site The surgeon prescribes antibiotics and tells the patient to check back in a week if not improved On 1/17, the patient calls the MD and says that the purulent drainage has increased and now she has lower abdominal pain not controlled with pain medication Patient is readmitted to the hospital A CT scan of the abdomen and pelvis shows free air in the abdomen and a fluid collection in the pelvis that is suspicious for abscess On 1/18, the patient returns to the OR for an XLAP OP note documentation is a large abscess within the deep pelvic cavity The deep pelvic cavity is irrigated and the surgeon performs lysis of adhesions The JP drain is placed within the pelvis First question What SSI criteria is met? >> And the lucky winner for question one is table 12 Where’s table 12? Someone from table 12 step to the mic and offer an answer >> Number 3 >> Yea >> Good job >> Yea. Woo! [ Applause ] >> I guess they’re after We’ll — okay What is the date of event for this SSI? >> Table 24 Where is 24 Don’t [inaudible] up here? Here we go >> It’s number 2 >> Great job [ Applause ] Okay. So let me just talk about the rationale You got it right but there’s a CT of the abdomen/pelvis that suggested infection This meets criteria c. OREP is met because of that deep pelvic cavity where they had evidence of infection So your date of event is 1/17 and that’s the date that you use to meet the organ/space SSI criteria

Okay. Now on 1/22, this poor patient remains in the hospital with complaints of intense abdominal pain and vomiting A CT is performed that shows a possible post-op ileus On 1/23, the patient returns to the OR for an XLAP Operative findings reveal two perforations in the ascending colon, a right hemicolectomy is performed So a COLO is performed And liquid stool is noted in the abdominal cavity No cultures are collected The surgical incision is closed to the fascia level, skin is left open, and a wound vac is placed What SSI criteria is met? >> And the lucky winner is table 8 It’s like bingo [laughter] >> Okay. We think the SSI criteria is not met It’s just a dirty case >> Yea! [ Applause ] You’re correct >> Really excited about this Okay. What is the date of event for the SSI? >> Table — nope Table 16 gets this one [laughter] >> They get the hardest question >> 16. [laughter] >> We think the answer is 4 [laughter] >> I think you’re right [laughter] And the rationale is because liquid stool is contamination but not evidence of infection There’s no evidence of infection noted on 1/23 in the operative procedure report On 1/25, the patient spikes a temp of 39.8 and blood cultures are collected A wound care RN visits and documents yellow drainage from the midline wound and a facial dehiscence at the time of the wound vac change Patient returns to the OR for laparotomy and abdominal wound closure XLAP. The surgeon notes cloudy fluid collected near the anastomosis Pathology of colon is collected On 1/26, ten hours after the conclusion of the 1/25 XLAP, the patient returns to the OR for an non-NHSN operative procedure via the same incision for control of the post-op bleed On 1/25, blood culture result, 2 out of 2 Klebsiella oxytoca And on 1/30, path results mucosal abscess of the colon What SSI criteria is met? >> Table 27 [laughter] Be brave >> We have number 1 >> Okay. Great job Woo-hoo >> Number 1 is absolutely correct This is an organ/space SSI, a specific site GIT with a secondary BSI Actually, this is — that’s actually the updated GIT that we updated the definition for this year and that’s utilizing that updated criteria So what is the date of event for this SSI? >> Table 2 Does table 2 decline? [laughter] [ Laughter ] Up. Up, here they come >> The group’s consensus is number 2 >> Correct Great job And then what operative procedure gets the SSI attribution? 1/23 XLAP, the 1/23 COLO, or the 1/25 XLAP >> Table 14 >> COLO 1/23 >> Great job Does PATOS equal yes? >> Table 10 >> We guessed a no >> Great job Okay. Let’s just quickly talk about the rationale On 1/25, the histopath report indicates a mucosal abscess of the colon This meets general organ/space criterion C. And then remember that GIT focuses on infections of the GI tract and therefore you apply GIT and not IAB in this case GIT criterion 1b is met because you have the evidence of an abscess noted on the histopathologic exam and positive blood cultures with a MBI organism So regarding attribution, this is when you would refer to Table 4 and you note the SSI is attributed to the COLO because of the level of risk is higher for the COLO procedure PATOS equals no because, again, liquid stool is evidence of contamination but not evidence of infection Great job >> All right I guess you guys are doing great On 2/3, the patient remains in the hospital The MD notes the patient has clear yellow drainage from her surgical site and new intermittent nausea A culture of the drainage is collected from the superficial incision and is positive for Enterococcus faecalis On 2/4, a CT of the abdomen is performed and shows a fluid collection

in the right upper quadrant that’s questionable for infection The patient returns to the OR for an XLAP, debridement of necrotic tissue and abdominal washout There’s no documentation of purulence or abscess noted Cultures of peritoneal fluid collected are positive with Enterococcus faecalis identified So what SSI criteria is met? >> And this question goes to table 21 [ Inaudible ] >> Ah, close It’s actually superficial incisional SSI [laughter] >> That’s okay You tried >> That’s okay You guys have done a great job so far and I understand if you didn’t quite get that far So the next question is, what is the date of event for the superficial SSI? >> All right So maybe I’ll start by saying this is for table 3, did you get this far? Table 3. If not, we can take a volunteer Oh. Here they come >> We chose February 3rd >> You’re correct So rationale for this one Sorry. There’s one more question What operative procedure gets the SSI attribution? >> Okay. So only one table left Don’t feel left out if your table was not called But this one goes to table 19 If they have an answer >> You are correct All right So let’s look at the rationale So in order to meet an organ/space SSI, you have to meet both the organ/space general criteria and the site specific criteria So we met organ/space criteria B and C but we didn’t meet IAB criterion 3a because there was only one symptom So you can’t site the organ/space SSI And you report the SSI at the deepest tissue level where you meet the criteria So we report the superficial incisional primary infection And the date of event is February 3rd And why not — why did we not report it to the non-NHSN operative procedure? Because you apply the 24-hour rule and therefore the XLAP gets the SSI attribution >> So give yourself a round of applause