Surgical site infection: first report from Scotland emphasizes
the importance of post-discharge surveillance
The first report from the Scottish Surveillance of Healthcare
Associated Infection Programme (SSHAIP) was published earlier this month (1).
Surgical site infections (SSI), also referred to as infections of the surgical
wound, are one of the most common healthcare associated infections (HAI).
SSI can result in a delay in patient recovery and increase in the duration
of hospital stay and costs associated with treatment of the infection. A recently
published study has indicated that the average cost of treatment is around
€4700 per patient (2). SSI is therefore an important outcome measure for surgical
procedures and a priority for surveillance.
A national programme of active, prospective SSI surveillance has been implemented
in Scotland through collaboration between the SSHAIP team, based at the
Scottish Centre for Infection and Environmental Health (SCIEH), and staff
in the acute hospitals. This programme resulted from a Health Department
letter, which required acute trusts (grouped hospitals) to have structures
in place by April 2002 for surveillance of in-patient surgical site infection
for at least two operative procedures (including one orthopaedic procedure)
from a specified list of nine categories of surgery, and to make surveillance
data available in 2003 (3). The first report of the data was published on
7 October 2003. The report summarises data reported to SSHAIP for the period
1 April 2002 to 30 June 2003 and is available on the SCIEH website (http://www.show.scot.nhs.uk/scieh/).
In order to obtain robust and comparable national data, surveillance in
Scotland is conducted according to the SSHAIP national protocol, with consistent
adherence by all trusts to the standard definitions. The SSHAIP team has
trained staff in data definitions who liaise directly with a named SSI surveillance
coordinator at each hospital site. Quality assurance mechanisms are in place
to ensure that the correct criteria for infection are applied for the definition.
These definitions, including surgical site infection definitions, have been
developed by the United States Centers for Disease Control and Prevention
for use in the National Nosocomial Infection Surveillance (NNIS) programme.
The dataset collected by the SSHAIP programme is compatible with United
Kingdom (UK), European and worldwide datasets, encompassing the Hospitals
In Europe Link for Infection Control and Surveillance (HELICS) dataset and
the NNIS programme.
The first report presents the results of the analysis of these preliminary
data. It must, however, be emphasized that the results provided in this
report do not represent infection rates in Scotland as a whole. The data
are heavily biased towards results from those trusts that have contributed
large numbers of reports, and so these data should be interpreted with due
caution. Results are presented for 128 in-patient infections from 7586 procedures.
The data are stratified using the NNIS risk index (4), and the infection
rates quoted vary by procedure and are broadly similar to those presented
by NNIS (5).
The SSHAIP SSI surveillance scheme is the first national surveillance scheme
in the UK to have published information on surgical infections occurring
after discharge from hospital. Trusts have established post discharge surveillance
utilising direct observation of the patient by staff, for example, community
midwives, who have received training in the data definitions. The surveillance
is coordinated by the named coordinator at each site to promote robustness
of data collected. In total, 349 infections from 5829 procedures were reported
by the trusts performing post discharge surveillance. Of these, 97 were
in-patient infections detected during the post-operative stay in hospital,
24 infections were detected on readmission to hospital, and 228 were detected
through post-discharge surveillance.
The report indicates that post-discharge surveillance is an important area
for development of national surveillance of SSI. For those trusts that performed
post discharge surveillance, 65% of infections occurred after discharge
from hospital. The proportion of SSI detected after discharge varied by
procedure and was most frequent for breast, abdominal hysterectomy, and
caesarean section procedures, which might be expected due to the short length
of stay associated with these procedures. The report recommends that these
types of surgical procedure should be prioritised for post-discharge surveillance
of SSI, and this is included in the SSHAIP protocol.
In trusts where data collection has been established for a year or more,
results have been fed back to clinicians to facilitate review of practice,
and as a result, some local improvements have been noted. It is anticipated
that as a more robust dataset is collected, trust-specific data will be
available for comparative purposes in future reports from SSHAIP.