916 Disjointed to Jointed: Implementing an Enterprise-Wide Orthopaedic Surgical Site Infection Surveillance Program

Sunday, March 21, 2010
Grand Hall (Hyatt Regency Atlanta)
Megan DiGiorgio, MSN, RN , Cleveland Clinic, Cleveland, OH
Miriam Rosenblatt, BS , Cleveland Clinic, Cleveland, OH
Eric Hixson, Ph.D., MBA , Cleveland Clinic, Cleveland, OH
Keith Rosenbaum, MCIS , Cleveland Clinic, Cleveland, OH
Boris Bershadsky, Ph.D. , Cleveland Clinic, Cleveland, OH
Greg Strnad , Cleveland Clinic, Cleveland, OH
Richard Parker, MD , Cleveland Clinic, Cleveland, OH
Mark Froimson, MD , Cleveland Clinic, Cleveland, OH
Joseph Iannotti, MD , Cleveland Clinic, Cleveland, OH
Steve Schmitt, MD , Cleveland Clinic, Cleveland, OH
Steven M. Gordon, MD , Cleveland Clinic Foundation, Cleveland, OH
Thomas G. Fraser, MD , Cleveland Clinic Foundation, Cleveland, OH

Background:  Surgeons in the Orthopaedic and Rheumatologic Institute (ORI) at the Cleveland Clinic perform procedures at multiple locations across a northeast Ohio healthcare system.  Prior to 2009, targeted surveillance for surgical site infection (SSI) was decentralized and geography-based.  A comprehensive view of the SSI rate of each surgeon and the group as a whole was not captured.

Objective: To establish an enterprise-wide ORI SSI surveillance program

Methods:  A multi-disciplinary project team met monthly starting 9/2008, with an Infection Preventionist (IP) serving as the project coordinator.  ORI surgeons and their operating locations were identified.  Using current procedural terminology (CPT) codes from a query of the Operating Room Information System (ORIS), procedures identified for surveillance included primary and revision hip, knee and shoulder arthroplasties and clean knee and shoulder arthroscopies.  Case finding was done by IPs assigned to the various geographic sites.  SSIs were defined using CDC definitions and identified by culture reports.  Case finding was supplemented by verbal reports, Infectious Disease consults, and letters to surgeons. 

Surveillance was performed by 4 IPs and SSIs were sent to the coordinating IP and warehoused in an infection control database.  Infections (numerator) and cases (denominators) were then exported to a data warehouse where data integrity checks were performed.  Calculated SSI rates were stratified by department, procedure, facility, and surgeon.  Rates were disseminated to the department chairman and quality review officer via portable document format.

Results:  6,107 procedures were performed by 45 ORI surgeons operating at three hospitals and four ambulatory surgery centers through 3rd quarter 2009.  Compared to all of 2008, the total cases meeting criteria for surveillance increased 27% through 3rd quarter 2009 and the number of ORI surgeons increased by 16.

The overall SSI rate was 0.6% (36 SSI / 6,107 procedures): this included 0.8% (21 / 2,471) for primary arthroplasties (hip knee and shoulders); 2.7% (10 / 369) for revisions; and 0.2% (5 / 3,267) for arthroscopies. The most common pathogens were Staphylococcus epidermidis (22%), Staphylococcus aureus (18%) and Pseudomonas aeruginosa (16%).  Timing of antibiotic prophylaxis for cases of SSI was 86%.  Surgeon-specific SSI rates did not differ significantly.

Conclusions:   We were able to establish an enterprise-wide approach to orthopedic SSI engaging a multidisciplinary team and information technology.  Addition of process metrics, a SSI dashboard and readmissions will be added.