rectal cancer urinary retention

>> good morning. my name is janet brooks. and i'm going to becovering the ssi protocol and anything and everythingrelated to that. and i want to say welcome to everybody here andalso those of us who are joining via web streaming. so it's great to haveeverybody here and get started with ourmega ssi protocol.

we'll go halfway throughit and then break for lunch and then pickback up after lunch so everybody willget a break and my voice will geta little break. let's get started. our objectives today is uponcompletion that you're-- we're going toidentify the ssis and we're going to reviewall the key terms that have to do with our ssi protocol.

we're going to havesome case studies scattered throughoutthe presentation. we're also goingto describe any of the 2016 changes tothe ssi protocol which are real minimalin comparison to our, you know, kind of bigyear last year of 2015. i do go over becausewe don't do in a lot of detail in theother protocols, entry of the numeratorand denominator

data into application/forms. and a little bit on howto link your procedures once you find asurgical site infection. and again we do the case scenarios. why do ssi matter? well they matterbecause right now currently surgicalsite infections and pneumonia are thetwo most common hais. the estimated ssi infectionsin the united states are--

over 157,000 per yearand over 8000 deaths are associated withssis each year. and an estimated 11%of those deaths in intensive careunits that occur are associated with asurgical site infection. so these are major and really important to try to control. again, they can cost up to 3.2 billion attributablecost per year

for acute care hospitalsand an estimated increased lengthof stay of 11 days and they're alsothe most frequent cause of unplanned readmissions and we all see that with our readmissions. it isn't as common thatyou actually see the surgical site infectionhappen during the stay they have the surgery butit's more on readmission. i'm going to reallykind of pull apart

the ssi portion ofthe nhsn website. i go to this myself dozensof times a day probably. it is-- has a wealth ofinformation and last year we did the updatewhere everything is on drop-down so it's a wholelot more user-friendly if you're using an ipad or an iphone. so let's take it apart and see what's available for you here. the training one's at the top.

that's this-- this training will eventually be on the website. so you can see thatwe have every kind of training youcan imagine here. we also-- this is whereyou've heard people mention hot topicsand quick learns. that's where these live. and you can see we'vealready entered one of the hot-- new hottopics for this year.

we put together one forthe most frequently asked questionsrelated to patos. so you'll see that they are the first one under hot topics because we get a lot of questionsin the mail box. is this patos, isn't this patos, should i select patos equals yes on this surgical site infection. so i didn't because oftime i'm not spending

a ton of time onpatos, some today, but i want to make sureeveryone knows there's a quick learn, you cantake related to that. now when you go down the next one is your protocol section. now for-- this mirrorsalmost every other part of the protocolsthat are out there, the first one is you findthe new 2016 ssi protocol. but under every protocolsection we also

put what we call chapter1 and chapter 2, introduction the overview of nhsn and identifying hais fromthis current 2016 protocol. and we also haveyour patient safety reporting plan available there. and this is true when you go to most of the other protocols. frequently asked questions. i think some of uswould think that this

might be our mostunderutilized section. we have-- for everyprotocol we have frequently asked questions thatwe put together. i think the ssi one is over 11 pages long. and many, many timeswhen you think you have a question youneed to send to us, it's good to kind oflook at the faq because we may have really addressedit there already. now these are last year's faqs.

we didn't want to pull them down until we had the new ones ready. but the new ones shouldbe ready in the next few weeks you'll see thenew ones are up there. and most of these arestill accurate we just always like toupdate them every year. data collectionforms, i think you've seen this section withsome other folks. this is where you actuallygo and you find your forms.

there's your first onethere we call it 57.120, that's your actualsurgical site event form. and then underneath it, youhave a table of instructions. every single form thatwe have has a table of instructions that tellsyou block by block, element by element what we'reasking for in that section. so it's really useful especially if you're new and are like, "wait, what do they mean by trauma?

how do they define emergency?" you'll find that in thetable of instructions. because it is-- every bit of it isn't in the actual protocol. i'm not going toput a lot of time into this because this is cms and this is coveredsomewhat in other areas. but there's a cmssupporting material section and my favorite ones isthe top two and that's

where they actually--you'll find listed the hai reporting requirements forcms, the current ones and you know it's the most up to date. what's required, sometimesi've had someone say, "well, is thisstill just colo and hyst that wehave to report for cms?" the answer is yes, they didn'tadd anything but this is where you can go right tothe source document and see. and then underneathit what i really

like are the deadlinesfor reporting. and we keep those up todate so you can look quarter by quarter andfind your cms deadlines. now the biggie is our ssisupporting material section. and we'll be coveringsome of these supporting materials later inthe presentation. but it says updated december 21st of 2015. the top two listedelements here are our spreadsheets thatreplace the old table 1

from 2015, the nhsn listingof operative procedures. so we're going to lookat that in more detail there's one for icd-10and one for cpt. i am going to address a frequentlyasked question here. someone will go to the siteand say, "wait, i don't-- i see a code but i don't think it's right." there were two updates that we did. these were first publishedand august and then they-- we did update in november anda small update in december.

so you need to makesure you're going to your source documenthere and it should be that the spreadsheets,they were updated in december so thenyou know you're in the correct one becausea lot of people go and grab that spreadsheet and thensave it somewhere else. now we always sendout a blast e-mail the day that it's been updated. all of you are goingto get an e-mail

that says, "we hadto make a change to the codes and they've been updated." and we list usually asummary of what was done. so please make sureyou're using the current set of codeswhen you're looking at your denominators butthis is just a quick look. this is also where you'll find guidance forsupplemental materials. so we made an hpro andkpro supplemental

guidance because under hpro and kpro there aresome procedure details you have to put in. and this guidance walksyou through being able to look at anicd-10 code and say, "is that a hemi, isthat a primary," and that's this guidance. and then we also madeguidance for fusion for the first time thisyear that tells you

if you look up an icd-10code we'll tell you is that, a anterior approach,a posterior approach, is it a cervical, is it a lumbar. that's new we've never had that before. and we also have thediabetes codes are updated. they were there lastyear but with this move to icd-10 whichhas been huge. you know, we went from,and i know everyone is feeling the pain ofit including coders.

we went from a few hundred codes to over 8000 procedure codes. it's been difficultand i'll address that a little more laterin the presentation. and we also updatedthe codes that are sometimes needed forhips and knees to note that there's been aprior infection at that joint in the 90 daysprior to the procedure. let's talk about yourmonthly reporting plans.

these are the plans that arethe roadmap to your data. this is where you'retelling us, here's what we're going to be followingand only the data that you check offthat says this is what you're followingwill be used by cdc in their aggregate data analysis. we have all been hearing these wonderful analysispresentations. rebecca's was fantastic.

that preceded mine where we got to hear all about ssi analysis. but when you check offand put some procedure in your plan, that'sgoing to enable it to be analyzed byyou internally and by cdc against other facilities. your plans drive thebusiness logic of the nhsn application andthat's important. when something isin plan, you're

going to have business rules that live behind thoseprocedures and events. and you have to have onefor every month of the year. and you must fully follow the definitions. i've definitely gotten thisquestion in the past. "well, i'm followingjust colo and hyst because i have to for cms. and that's ok if that'sall that you can handle-- based on yourburden or your resources.

but do i only have to give you my deep and my organ space ssis because that's all that cms wants." and the answer is no. that's what we'll sendto cms but when you're following a protocolyou fully follow it for superficial, deep and organ space. now surveillance, that's the key of this. how are you going to findyour surgical site infections?

so you'll have todetermine which patients you're going to monitorand those are going to be the patientsobviously that had the procedures you've marked in your monthly reporting plan. you can review youradmission notes, your readmissions, youred and your or logs. that's one thing. i in the past would geta list of every single

readmission to thehospital or admission because you--sometimes you can't tell how long they've been gone. and look at their diagnosiswhen they came in. and you can get those lists, you know, if you build those reports and you'll know youmight see the word abscess, you might seethe word infection. now it doesn't meanit's going to be

an ssi but itcertainly a red flag that this is the patient's chart that you're goingto take a peak at and see if they did havesurgery in the last, 30, 60, 90 days depending on whatprocedure they have. you can then review thepatient's charts for signs and symptoms ofsurgical site infections, the risk factors, reviewlab data, radiology reports, otherdiagnostic reports,

review nurses and physicians' notes. and if you have theability, and we all don't have it, it's wonderfulif you can get in and some sort of regular pattern of doing ward and icu rounds. sometimes they haveweekly multidisciplinary rounds and you reallyhear a whole lot about what's going on with the patient. i can't emphasize how important

it is to not feel as though-- not to feel asthough, "i'm ok if i just get a list ofany wound cultures." that's going to be just a little tiny slice of thepie that is going to help you find yourpatients who may have developed asurgical site infection after procedure. because as you see when we start

going over the definitions, you can absolutelymeet a surgical site infection withouta wound culture. so i think that'simportant to feel good about yoursurveillance plan. there's also the issue ofpost-discharge surveillance. now this is where you canlook at your surgeon, some places have setup for surgeon surveys that they sent lettersout, sometimes

they send patient surveys out. some facilities actuallyhave the ability to do phone call followupwith patients or connecting with surgeon's offices. you can do a review ofpostop clinic record. some systems especiallythat are very connected and have a lot oftheir clinics linked in with theirelectronic reporting can go right to looking

at any clinic visitsthe patients have had or visits towound care clinics. and then again thisis where you want to look at a line list ofall your readmissions with the diagnosis,another tool that i've definitely used in thepast was getting a list of all my er admissions eachday with their diagnosis. and you can sometimes find er admissions for patients who came

in definitely had awound infection but it wasn't severe enough thatthey got readmitted. so that's another, just another little thing youcan be looking at. and there are some facilitiesthat have actually built-- or do we have anyone from california here? scattered around afew tables, that's where i was before i came here. they have actually builtin a list of codes that

you could run after aperson had been discharged that will give you--they're more icd-10 diagnostic codes ratherthan procedure codes that would give you a head'sup that this person-- patient may have had asurgical site infection. and there was a paperpublished that i used to be able to have a link to that had the icd-9 codes for those. we don't quite have-- idon't have a link for

you yet for icd-10 butthey are out there. and that's againwhat i'd call some enhanced surveillanceyou can do. and again thecriteria must be met no matter where thessi is detected. when you saw-- heard rebeccatalking about the analysis, there is some analysis done on-- readmit. but in terms ofwhat we share, what we look at, you'dlook at all methods

in which you founda surgical site infection includingpost-discharge and that's important to remember. so here's our twoforms with the-- always with ssi, we'retalking double. you've got your denominatorcollection form on the left and your surgical site event, as i call it, form on the right. these-- when you're using a form, you--

these kind of mirroralmost exactly what then later gets put into theactual application. when i talk about theapplication, it means you're in nhsn and you'reentering the data. can i ask for a little show of hands and i'll try to remember to tell the folks who are web streaming. how many of youare entering your own data into the application?

yes, it looks likemaybe about a quarter and it means thatthe other folks and so i was spoiled in the facility i camefrom, it was large and we had a data entryperson so we did use the paper forms theywere very important. or some of you mightbe using, you know, a vendor provided system where you're putting it inand then it's uploading.

but there are still--it sounds like quite a few of you thatare using the form and then later get putinto the application. let's review a few key terms. a lot of these were covered. they don't change so-- but i also saw a lot of hands come up that you're first timers here at this presentation.

so it can be tricky. we could have a brandnew person here who's maybe been in theirposition less than a year and i know because i know thefaces like the white on top that we've been doingthis for 25, 30 years. so we try to hit ahappy middle ground on our presentations ofnot making it too hard for the newbie and not makingit too easy for the person. and that-- but that's-- there's

a sort of sweet spot in there and it can be a little tricky to hit. i want to point out,this is a little part of our chapter 2 as we callit identifying hais, where i've actually crossedoff in red to remind you because we do stillget questions like, "well this should havebeen present on admission that the poa definitiondoes not apply to ssis." neither the-- ssisdon't have seven

day infection window periods and you can think why that would be. whey can't they have it? they-- because theyhave like 30, 60, 90 days surveillanceperiods depending on the procedure you go as far as 90 days. poa doesn't apply becauseas soon as you go to surgery that starts thesurveillance period. so, we'll talk about more of that later.

and present onadmission you can't say, "oh, it waspresent on admission but at least we havethe patos field now," so we'll talk about that. we don't apply the haidefinition because the hai definition is allaround what happened in the first twodays, what happens the day after their discharge. again, ssis are just a littlespecial as we call them.

and they don't have a14 day rit because they have their ownsurveillance periods. they do have their ownsecondary bsi timeframe which we'll address laterand pathogen guidance that is associatedwith that and we'll get into that in theactual application. but i just want to remindeverybody that, don't apply these things tosurgical site infections. now we didn't reallyhave any change in our

definition of an nhsnoperative procedure. my slide is a little bit different. i really try tosnag anything that referred to table 1 or icd-9s. but right now an nhsnoperation it means it's one that's includedin the icd-10 or pcs or cpt operativeprocedure code mapping and takes placeduring an operation where at least one incision

including alaparoscopic approach, this is made throughthe skin and mucus membrane, or becausewe now have procedures that you report where thereisn't a primary closure. it can be re-incisionthrough wound that was left open froma prior procedure. and it takes place in anapproved operating room. none of that lingo has changed. the date of event also did not

change for surgicalsite infections. it's-- and it'svery-- it's every bit same as all the other criteria-- the first element usedto meet the surgical site infection criterionfor the first time. although we'll getinto a little caveat when a surgical siteinfection continues to progress during the surveillanceperiod then we have to have a little extraguidance for you there.

and here is that extra guidance. so remember, youdon't ever apply two ssis to one nhsnoperative procedure. you report one surgical site infection to themost recent trip to the or through that incision, ok. but if during a person'ssurveillance period, the initial ssi thatyou found, you know, you thought you--if is they've got

pus coming out of this incision, you're on your game you'redoing realtime surveillance and you document asuperficial incisional ssi. then it moves to a deeper level. what do you do then? so this example they had a colo on day 1. and on day 6 theydid have a date of event for a superficialincisional ssi. but then they comeback on day 25 they're

still in their 30 daysurveillance period, it actually hasprogressed and it now is meeting criteria for aorgan space iab ssi. so what you're goingto do you only report one ssi but you are goingto choose the date of event for the organ space when it fully met organ space. so you can just pullthat superficial one and update it,and change the date.

but if you're like alot of us maybe that superficial isn't evenin your system yet, so. now pathogen assignmenti just have a little new post-itnote there next to what you've alreadyheard about from kathythat we did decide on this group of organismsthat we're not going to say you'll call anssi to or an hai to. so those are also excluded for ssi.

and because we havethe long surveillance period with pathogen assignment, let's say you had someone, you know, who hadpseudomonas coming-- in a wound and then that wound is not healing and there's-- you still is justongoing ssi and now mrsa has showed up in the wound. you just tack that on ifyou're still at the same level.

you add that pathogen on, you capture it. and that's no different thanwhat we have been doing. our definitions of aprimary wound closure and an other than or whatwe often call open, did not change in '16so i'm-- for saving of space i didn't putthem all back in, in text but thisreally shows it very visually that a primaryclosure the one on the far left is--that's one that's

really shows it'sstitched up tight. but if they close theskin at any level, less, fewer skin is still meetsa primary closure. it's only closuresother than primary where it's fully,you know, open. and we did get questionsabout retention sutures. retention sutures, youcan't look at that word alone and just say, "oh,i see retention suture that means this, open close whatever."

they'll use retentionsutures on primary closure and they sometimes useretention sutures on a open one as the example i have. so you're going to haveto get in a little bit to the op-noteand know what kind of closure it was when yousee retention sutures. and some people havebuilt this closure method into theirop-record or some place in their operativerecord based on the nhsn

definition so they'recapturing this in the or and they've educated theor what the definition means and that's howthey're following that, other people are stillneeding to look and actually manuallylook at a quick-- you know, we allknow you run to the bottom of the op-notewhat did they do, you know, what did they do to that skin? and you're doing it manually.

questions about packing and wound vacs. sometimes we get asked if they put a wound vac on a wound, does that meanit's automatically open and the answer is no. there is-- it really depends on again the skinclosure so that one on the left that's apack but that's an open. other than primaryclosure, you see

there's no closureat the skin level. and that wound vac isrepresenting a case where they did not close theskin at any level. you can see it's all around the wound vac. there are situationswhere they do close the skin and then lay awound vac on top to aid with the healing anddrainage of that wound. usually, you know, infairly contaminated cases. so for denominatorreporting and this

changed about twoyears ago i think. it-- as you all knowespecially for those of you who've beenin this awhile, it used to be the onlyprocedures when you were following annhsn procedure group in your monthlyreporting plan, you'd only send nhsn theprimary closures. and we changed that. we basically, if youdid a colo, if you did

a card procedure whetherit was left open or closed we want itin your denominator data and that's whyfor every denominator that you enter it hasclosure method on it. so you're sending usall of them and you're telling us at theclosure method, ok? it keeps it easier in termsof running your lists. again, what you saw rebeccashare what we send to cms for your colo andhyst are only the ones

that were closed primarily at this point. because they're based on2006 through '08 data and that historically was always just the primary closures. let's do a little case, get your-- i call themyour clickers, i don't know what everyone calls it, your garage door openers? no, it won't work.

don't take it home. so case 1, a patient is admitted with a ruptured diverticulum and a colo procedure is performedin the inpatient or. the case is entered as a wound class 3. a specimen is obtainedin the or which later returns positive for e.coli. the surgeon staples theskin at four locations with packing placed inbetween the staples.

is this procedure consideredprimarily closed? and the polling started. rebecca wanted 100%,and cindy's vae questions arestill so challenging, i would flunk the test if i was taking it. but i think you'll dopretty well on this one. all right, i'll give youabout five more seconds it looks like mostpeople have completed. ok. let's talk about that.

we've got about 20% of you that aren't really clear on this. is this procedure closedprimarily and the answer is yes. here is your rationale. remember when i describedthat, look back at the slide it saidthe skin was closed and some packing was placed in between. so as soon as you seethat the skin was closed at four points withpacking in between.

this is the quote from the definition. thus, if any portion ofthe incision is closed at the level of theskin, by any manner, a designation of primaryclosure would be assigned. is everyone clear on that,so that makes sense now? ok good. so let's think aboutthis same case, all right. so now you know. if you're following colo inyour monthly reporting plan, should this case be enteredinto your denominator data?

you can pass thoselittle voters around the table so everybodygets a chance or have discussion,discuss among yourselves. all right, i'll giveyou about five more seconds, you're allquick-- these are-- i'm starting you off pretty easy. and the answer-- almost everyone of you got this right. but i always like-- let's help the little 2%'ers here, ok?

remember what i was sayingis that if you were following colo in yourmonthly reporting plan which most of us are forif i fall under the cms reporting guides, youreport all of your colos. you've told us whatthe closure method was but you sendthem all to nhsn. let's talk a little bit. i said that yes wedo obviously have to have secondary bsi timeframe

for our surgical site infections. they're a littledifferent because a secondary bsiattribution period for ssi is a 17-- it's alwaysgoing to be 17 days. it's not going to shift at all. and that includes your date of your event and then you go the threedays before you have available to attribute a secondarybsi and 13 days after, ok? so that's set.

this 13 days can fall outsideof the surveillance period. we get that questionbased on the date of event and think of that. for example, you have a dateof event that was on day 29. it fits into your 30 daysurveillance period. but the secondary bsiperiod will extend beyond the 30 daywindow and that's ok because the eventis in the 30 day surveillance window,you find the bsi

and you just select bsiyes for that event. well why does ssi have to have its own bsi attribution period? well if everyone hasbeen processing what you've been hearingyou'll kind of know from what kathy's veryfirst one covering chapter 2, a lotof those elements. for other hais, thesecondary bsi attribution period is determinedby a combination

of the infectionwindow period and the repeat infection timeframe. so, voila, we do not have those for ssis. so they got theirown little special ssi secondary bsiattribution period. and this sort of shows it visually. so there on the 13th, it's your date of event for an ssi. there is your secondary bsi

attribution period going from-- the 10th to the 26th,the three days before and the 13 days afterfor a total of 17 days. i don't have to stay on thistoo long because all of us grab the same two elementsthat we want to show. in terms of how to meetwhat you can do to meet a bsi to an ssi, thatis the same definition as all the others, theblood culture that occurs during that secondarybsi attribution period,

you assess it using appendix1 in the bsi protocol. and if a blood cultureoccurs after the ssi secondary bsi attributionperiod, it's over, it' happened afterit, you'll have to fully assessthat blood to see if it is meetingprimary or meeting criteria secondaryto some other event or is it meeting criteriabecause that horrible intraabdominal infectionis still ongoing

and you can meet itagain outside of the 30 days surveillance periodso that is important. so let's talk a littlebit about patos, infection present atthe time of surgery. so one of the thingsthat comes as a question a lotis, is this-- a person goes down andhas their primary-- it has their indexi'll call it surgery, they go down for thatfirst colo procedure.

and they do have a big abscess in their abdomen and some-- people will say to me, "is this procedure patos equals yes?" and i just want to remind youthat patos is not linked-- we are not collecting thatfield on a surgical procedure. you only fill patosequals yes when you think you mighthave an ssi, ok? so in terms of laborintensity meaning it's

up to you but it's notthat we ever expected that every singlepatient who went to an or, you'retrying to figure out for every procedure performedis that a patos. the patos only gets lookedat when someone comes back and now you thinksomeone has an ssi, then you go back for thatone particular patient you're assessing andsay, "oh, let me go back and look at that original index procedure

and see if there wasinfection present at the time of the procedure." so it means there isevidence present and we'll call it the indexprocedure at the time of, or start of, or during theindex surgical procedures. in other words, it waspresent pre-operatively. this field is arequired field and it is found, again,i underlined it. it's on your ssi event form.

it's not on your denominatorfor procedure form. so the evidence ofinfection or abscess must be noted, documentedintraoperatively in an intraop-notewhich is often your immediate postopnotes it's not like they're, "ok here take this note." they get that notewritten and they tell all the findingsfrom that procedure but some people call it theimmediate postop note.

and again remember there'sa quick learn for this. some of these slides i snaggedfrom the quick learn. but again like rebeccagave you some homework. now that you know whereit is, you know it's in training and it'sunder quick learn. and we make these quick. there's more coming, definitely. but they usually will onlytake you about 10, 15 minutes. and we, again, thiswas us responding

to your needs andsaying, "you know, sometimes we don't have twoand a half hours to-- you know, to get in front of a computer and take a training." so we have discussionsof what do we feel based on our most frequentlyasked questions could be a good quicklearn for this year? so i did two this year,the next one i'll tell you about later it'snot quite up yet but.

only select patos equals yesif it applies to the depth of the ssi that's being attributedto the procedure. so again you've gota chart in front of you, you thinkyou may be dealing with a surgical site infection, ok? so if a patient hadevidence at the time of their initial procedure of an intraabdominalinfection at the time of the surgeryand then comes back

in with a big organspace intraabdominal infection the patosfield would be selected as a yes. because the-- butif that patient had returned with asuperficial incisional or even a deep incisional, that patos field wouldhave been a no. they didn't have anyissues with their skin and the softtissue infection it was

in the deep intraabdominal space. the patient doesn't haveto meet nhsn definition of an ssi at the time ofthat primary procedure. we're not saying thatyou then when that initial colo was performedyou're in there and you're applying our iab definition. it might be that all youfind is the physician says, "patient hasintraabdominal infection. saw infection in the abdomen."

that meets it. we're not saying you haveto-- you know, that's-- we kind of like put it inthe cart before the horse thing. i'm going to apply iab atthe time it's original. but you do have to have theevidence that's important. and that's why i thinkthe quick learn really gives you some verydistinct examples. this could-- would be ayes, this would be a no. this is a little screenshot of

where you'll findthe patos field. it's right underyour event details on your form andit's just a yes, no box and it is a required field. there is a littleshot of it right there, new patos quick learn. and you can go via youtubeand view it or just a streaming video thatwe have, either place. let's try another case here, ok.

so a patient was admittedwith an acute abdomen, they went to the or foran xlap with findings of an abscess due to a ruptured appendix and anappy was performed. the patient returnstwo weeks later and meets criteria for anorgan space iab ssi. does this patient meetthe criteria for patos? one, the patos field should be no. or two, the patos fieldshould be selected

as yes on that surgicalsite infection form. i'll give you about five more seconds. i know you're going to get 100% on this. oh, 93? it's ok. it's ok. that's why we're doing this. remember when they had that original, look back two slides when they have the coloprocedure there was a big abscess-- when theydid the appy rather.

there was an abscessthere, which often happens if it's, youknow, ruptured. and so that meant--then they went and came back two weeks later and there's an abscessit's reformed which you see with thoseappendectomy sometimes. so that is a patos equals yes. this ssi is related to aninfection that was patos. so that's true, we justdetermined that, right?

therefore it does not haveto be reported to nhsn. so we figured outlike 93% of you figured out yesyou're going to put-- check the patos box on that iab ssi you're going to report. but then what do you do? do you need this? you know it. you figured that but do you need

to have to report that to nhsn? this is related, just kindof a double negative here. there was a patos so you don't have to report this to nhsn is that a true statementor a false statement? all right. looks like everyone'spolled, i'm going to pull the trigger here. that is a false statement.

it is an event. it is an ssi. there is nothinganywhere that says if you select patos equals yes on an event that's an exclusion, no it's not an exclusion. you have found a surgical site infection. we started collecting patos in 2015. it is part of that intenseanalysis along with--

and this was hard workwe put on you but we-- you wanted this, wewanted to be able to tell nhsn this infection hada super high chance of getting an ssi becausethere was an infection present at the time ofthe initial surgery. you're selecting bmis nowwith those high weights because we know that'sa risk, your diabetes. so all these are nowcoming into play and magie has herown full presentation

about this with ourre-baselining we're doing-- we're looking at allthis new data that you've given us andwe're going to look at what's significantand what is going to be used and isnot going to be-- going to be used, andwhat will be sent to cms and what mightnot be sent to cms. the rationale, patoswould be selected as yes but since there wasevidence of infection

at the time of surgeryand the subsequent ssi developed at the same level. infections that meetssi criteria and have the patos field as yesas reported to nhsn. so i'm going to say something, all right, i don't think i'm tellingtales out of school i hope not. i guess i could. i'll get-- i can get reprimanded later. i don't think so.

so just did someanalysis, you know, that wonderful paperthat we're talking about that you all can read. i just sent that to some ofmy colleagues this past week. i love that paper. that's the one we're reworking on, the new modeling paper. but they were-- sothey're analyzing all this informationwe've been getting

and they found a chunkof facilities that have never sent us a patosequals yes infection. and we're like, is thatbecause they-- it's just this facility wherethey do a whole lot of super, super cleaninfections or is there some hospitalsout there that have-- and that's why i'mputting it out there for everybody listeningand everybody here. those ssis that meetpatos equals yes they

were supposed to bebeing sent to nhsn. so if we're-- if it'sa facility where they've never got asingle one its like, "what's going on?" i said, "i'll call them." and they said, "no thank you janet. you don't have to do that." i'll ask. i'm not shy. so, let's do another case,a patient is admitted

with a ruptureddiverticulum and in the or report the surgeonnotes there are multiple abscesses in theintraabdominal space. we've all seen and read that report. the patient returns threeweeks later and meets the criteria for asuperficial incisional ssi. the patos field shouldbe selected as, one, patos equals no, ortwo, patos equals yes. all right, five seconds.

all right, so the answer ispatos equals no, all right? now, so that'sagain we got about 25% of you want to review this. here is the rationale. remember in the patosdefinition the patos field would beselected as no since, remember you're goingback and looking at that index procedure, therewas no documentation or evidence of infection or

abscess of the superficial area of the skin at the time of the procedure. it's going to be pretty unusual that you-- at least based on what isee and the questions i get that you wouldhave a superficial incisional patos equals yes. it would have to besomeone where they're incising through somenecrotizing fasciitis, some horrible infected,they'd be making the

incision through basicallysome skin that kind of had infection but itwas the only option for going through with thatarea there is infection on the skin and that's wherethey make the incision. so just kind of tuck thataway that it's pretty unusual for a superficial incisional infection to havepatos equals yes. i don't get-- seeit very often in terms of questionsthat you all send.

let's do another one. so during an unplanned cesarean section the surgeonnicks the bowel and there is now contamination of the intraabdominal cavity. one week later thepatient returns and meets criteria foran organ space orep, that's other reproductivesurgical site infection. patos equals no for that orep

infection, or patos equals yes. this one is a little bit trickier. i give you about five more seconds. you guys are quick. i can tell you havea lot of experience with surgical site infections. and i'll close the polling. and the answer is patos equals no, ok? and the rationale, think--remember what patos means.

that patos field shouldbe selected as no since there is nodocumentation or evidence of infection or abscess, this was just unplanned c-section. the colon was nicked during the procedure. that's a complicationbut there was certainly no infectionpresent at the time and a nick isn't goingto give you time to set up an infectionat the time.

so did you have a complication? yes. will you maybe have had a procedure that when you think of your risk adjustment has a little bit higherwound class now? yes. but-- a high woundclass doesn't equal patos equals yes andpeople want to say, "well, it was a high woundclass and it was an emergency andit was a trauma."

it's like, well all thosewe're already going to look at. those are there but it isn't what patos necessarily means. our definitions forinpatient and outpatient operative proceduresdid not change from last year. so, again, you know, becausethere could be new folks. nhsn inpatientoperative procedure is performed on patientswhose date of admission

to the healthcarefacility and date of discharge are differentcalendar days. and an nhsn outpatient operative procedure in your acute care facilityis an nhsn operative procedure performed ona patient whose date of admission to the facility and date of discharge are different--or the same calendar days. and i just want toaddress here because i don't think i addressedit anywhere else.

this is-- this canbe different than what you would calla billing status. ok. you can have patients who are admitted to your facility. i'm going to pickhysterectomy or vag hyst who have theirprocedure performed in your inpatientacute care or, they are being billedas an outpatient but they are definitelyspending the

night, they'rein one of your units and that meets ourdefinition of an nhsn inpatientoperative procedure. and you can usually filter those pretty easily bygetting line list that show your hysterectomycases show their admission dates, showtheir discharge date, you know, and you'llbe looking at the ones that did spend the nighton one of your units.

so let's talk a littlebit about the new nhsn operative procedurecodes or transition to icd-10 and cpt code mappingsthat occur this year. i have to just take a bigdeep breath to head into this. we-- these codes wereavailable both under our acute care hospitalfacilities or our-- we also loaded the sameprocedures into our ambulatory surgerysetting because there's where our two table 1,so to speak, the old

table 1 list ofprocedures lived so that's where you could access themvia either of those sites, most of you i assume are going into your acute care facilities. you're going to go tosupporting materials. you're going to drop that down. and you're going tolook and make sure that whatever you're using,i ideally like to stay at the source you're goingto use your updated

december 21st make surethat's the spreadsheet that you're using. there you see the topone is your icd-10 the bottom one is your cpt,those are current. this is the first year. we always had in our oldtable 1 a small handful of procedures that haddual mapping for icd-10 and for cpt but there was a decision made thatwe would offer--

this would be the firstyear we would dual mapping to all 39 nhsnoperative procedure. so that's what we did this year. so this is a screenshot. i've opened up the mapping. i have my amputationsite circled, same name that wehad on table 1. i have my descriptor. now, we really made this look

very much like table 1 we just-- table 1 was a list ofcodes for amps, you've got your listof your icd-9 codes. we have the legacycode, that's what goes when you're enteringinto the application, this is an amp, anoperative procedure that how they mightcall it in or and then the descriptoris the same as we used in table 1, total orpartial amputations

of the upper or lowerincluding digits, so. it's really-- itfeels very different but we map this like this. i do want to tellyou that within our next updatewe are going to-- like i said we have had two updates. this is a fairly painful process. these mappings were donefor us before any coder had ever held a penciland opened a code book.

and so the realitywhen the codes started actually being applied, we have had somegrowing pains and that's why we had two updates. if you're using anold version and not the current one we realize after the mappingstarted being used that it was capturing procedures that were being done viacolonoscopies and endoscopies.

those are procedure 8 for your approach. and for colo groupand the appropriate groups like procedureswe did the update and removed all of those because it-- of course we didn'twant colonoscopy like a polyp removalduring a colonoscopy to be a colo they never were in the past. this is what the cpt code looks like. cpt codes are just five digit

codes, and this isthe same thing, this is the amputationsite for a cpt code. now how to search for a code? can i get a littleshow of hands of how many of you are usingthis search field? ok, good i'm glad-- ok. just probably a little handfulof hands went up, so. let's say you've got acode in front of you. someone has produced a line

list or you're just like, "wow, i can't tell i've gotthis icd-10 code is this a colo or is thismaybe a small bowel." you go up, this is just ascreenshot, go hit your find and select littlebinoculars there that's what you'regoing to do first. as soon as you dothat it's going to open up this box,find and replace. and you're going to putin your icd-10 code or

cpt depending on whichspreadsheet you're in. now, i'm in the colo spreadsheet. you can see that right here i opened up the colo spreadsheet. if i don't change thatdrop-down under sheet, it's only looking for the code i put in, in the colo worksheet. i as a habit because i'm looking at codes most ofthe day it feels

like now, i switch it to workbook. it's going to look throughthat-- for that code all the way from ourtriple a to our xlap, ok? so if it finds it, notin colo but says, "oh, nope, it's in oursmall bowel group." it's very, very, very helpful. so i just want tolet you know and then-- and you got that drop-- i'm sorry, that arrow under options.

that's the one you justselect that options and shift it over toworkbook and it'll look through the entire workbook for that code. and, if it doesn'tfind it it's going to say, "this isn't inthe workbook," ok? i want to tell yousomething really-- well i'll get to it laterso i won't tell you. i'll save it. now the transition to icd-10and pcs and cpt codes,

there were some growing painsas we've been saying. fusion, the spinal groupfusion now includes fusion and refusionbecause it was really, really tricky with thetransition to icd-10. they didn't clearly havecodes that could really tell us this was arefusion versus a fusion. and honestly they'reboth fusion procedure so we blended thosetwo groups into one and you'll only findfusion listed as a

tab not-- but itincludes refusion codes. and that is also true forcpt codes, all right? and this is the other big change is other. other-- those of youfrom pennsylvania are very familiar or probablymore than anybody with this what we calledare catch all, oth-other. it really was a procedure group. if you went to our icd-9 mapping guidance you'd see a bunch

of procedures that werecalled just oth-other. they were kind of a mishmashof different things. and you could--so-- and they had 30 day surveillance periods. but with this transitionto icd-10 we've really didn't feel like therewere the resources and the ability to tryto capture that volume and what it would entailin terms of icd-10 codes. so we did not map that bigprocedure group oth-other

to icd-10 code so it'ssort of just went way. it's not-- we're not saying the patient didn't have a procedure, just like in the pastthat they put a trach in. that wasn't an nhsnoperative procedure it's a procedure it'sjust not an nhsn operative procedure. so that's what happened to those procedures in theoth-other group.

now, for hot topics ihad to put a "coming soon" here becauseit's been built, it just hasn't been recorded yet but we're going to have just like i-- we did the patos quick learn. i did transition toicd-10 cpt quick learn so that you all can all-- there's even more thanwhat i'm showing here. i've tried to incorporate a lot

of them but if youget like fuzzy on things you can take aquick learn on icd-10. and as soon as thosequick learns are ready, you'll get a blast e-mailthat'll let you know they're available andthey're on the website and they'll-- you'll always find them in the training section. and it's not just--all the different ips are working on quick learns

so it'll be helpful little topics for you. so, now we're going to move a little bit into completing the denominator for procedure information form. and by the end of thisyou'll be able to guess what kind of dogi have at home, so. so here's your denominator form. again, not very many changeson it except that it had to reflect the change foricd-10 and cpt code.

the collection periodis one month or it can be up to 90days, you know. you complete thedenominator for procedure form for everyoperating, you know, procedure that meets thedefinition and that you're following in yourmonthly reporting plan. and you're going tosubmit your data within a month of the end of a 30day surveillance period or one month from the90 surveillance period.

that means the goal hereis what i want to say is to admit your informationin a timely fashion. but the most importantdeadline and, you know, we knowthis too, i mean, we can say that's what we'd like. but the most importantdeadline is to absolutely make sure you have yourcolo and your hyst data. you get a reallyhuge grace period for how long by theend of a quarter

that you should have your colo and your hyst denominator data and your surgical site infection but. we just say try toget in as quick as you can and we knowwith the transition to icd-10 it's causedsome lags in getting some of the denominator datain that we would like. but again if you thinkthat you have almost like, four and a halfmonths after the end

of a quarter to do this i think that's a prettybig period there. and once-- but i do wantto say because we do get this question is youwant to get your data in before the end ofcms reporting periods and you really don'twant to wait. that's a nightmare for all of us. but once your data hasbeen sent to cms it's-- and i think this wasaddressed in on of maggie's

team slide with a nicelittle word "frozen". that informationcan't-- they've got it it's frozen and theycan't change it. people ask me, "wellshould-- if i found something should--what should i do?" i said, "you can absolutely fix your own internal information. it'll make your informationand your analysis of what's really goingon very accurate."

so we encourage you. it's just we can't, you know, do anything with whatalready has been sent. if procedures inmore than one nhsn operative procedurecategory are done through the same incisionduring the same trip to the or, create a record foreach procedure you're monitoring in yourmonthly reporting plan, and use the total time for the duration.

again, i think and i can see why these questions arecoming through. a lot of reporting instructions,folks are asking, "well, is that still true with icd-10,is it still true?" we didn't change anyreporting instructions. they're still thesame-- most of the same reportinginstructions are true but it's just we havedifferent sets of codes we're trying to learn andget comfortable with.

so this example is thepatient had a coronary artery bypass graftwith a chest incision or actually cbgcsand also at the same time they hadvalve replacement which would be a card procedure. now, if you'refollowing cards and cbgcs at yourfacility you're going to have two denominatorfor procedure forms. and for each one of thosesince it's through

the same incision,they're all both going to have the duration of procedurelisted as five hours. you don't split when it'sthrough the same incision, ok? everyone clear on that? if a patient goes tothe or more than once during the same admissionand another procedure of the same or different nhsn procedure-- operative procedure is performed through the same incision,

this is what i call our 24 hour rule. within 24 hours of theend of the previous one, the original procedurereport only one denominator forprocedure form for the originalprocedure combining the durations of the two. so here's an example. a person had a colo procedureon tuesday morning which had a direction ofthree hours and 10 minutes.

then on tuesday evening,so we're not past 24 hours certainly,he returned to the or where the colo incisionwas opened and a colo was performed to repairan anastomotic tear. the duration of thesecond procedure was one hour and 10 minutes. so what you're going toreport is one colo with a combined duration offour hours and 20 minutes and you-- that second colo isn't

even like in yourdenominator data. the concept to this is thatwhen you have a return to the or for another nhsn operativeprocedure that quickly. the second procedure is really more-- it's being donebecause the original procedure had a complication that needed someimmediate attention and therefore it'streated almost as an extension of the first procedure, ok?

so and that's what we kind of-- you know, call the 24 hour rule. and this is when they're going in through the same incision. if a second procedure isdone through that same incision and you'rebeyond that 24 hour rule. that is a new separateoperative procedure, all right? now let's talk a littlebit about what do you do with yourdenominator reporting

if you have proceduresthat are performed via separate incisionsduring the same trip to the or? and this is again, it'sthe same procedure group so you couldhave someone who has-- and this is i have-- youknow, this is an ie. this lists all of the procedures where you can entertwo procedures with the exact same procedurename on the exact same day.

because for example you can have a patient of severe diabetic who has a right and a left amputation, ok? very separate sites, separate things, same trip to the or. if you're followingthat you would have separate denominator forms for each one would be completed. and if they didn'tnote the start

time and stop time for each one, you would actuallyjust take the entire procedure time and youcould divide it in half. sometimes you'll see where they've moved to the other side or you could even potentiallyhave two surgeons that are working one on eachside doing something. but again, these dobecome two denominators. let's talk a littlebit now about the

actual transition tothe icd-10 pcs codes. so, here is how it impacts the form. we're going to go through the form now. and that you will seeif, and this is the big if that i get a lotof questions about, if you're entering annhsn operative procedure where the date of theprocedure was performed in 2016, starting january 1st of 2016, the application is smart.

it went live in january. it is going to offer you, you'll open that up and you'll see in the applicationyou have a field to choose an icd-10 or a cpt. the 2015 application wasnever going to have that. if you were puttingin a procedure that was performedin 2015 all the way up to december 31st,again, what you've entered

the procedure you'llsee the application do its little,tud-tud-tud, and it's going to show youjust an icd-9 code. the icd-- yes we hadto start applying icd-10s many of us in october because that's when they transitioned. that's why in all thenewsletters and in the blast e-mails we gave youan instruction of what to do for that last quarterand we'll be getting to that.

maybe i didn't put it. if it's that lastquarter and i think many of you aregetting those in. because you only haveicd-9 field, well these codes arestill not-- this-- the actual code entry is not a required field inthe application. you do have to put theprocedure name in, you know, but the code isnot a required field.

so for that last quarter,you've got the list to help you know ifit's a colo or a hyst but in the application you'll just-- you won't put a 10 code in if it's a 2015 because you can't, you'll just put the procedure name. so now you're-- this is the new application here'swhat it'll look like. you'll have yourcolo field there and

then you have two radio buttons, one you could be icd-10, the other cpt. you don't have to put both,you can-- you're selecting. this'll then-- ifyou put in-- if a code is enteredinto icd-10 field, you see that someoneactually put in odtn4zz. the application has this loaded and knows that that's a colo. so it populated that colo,colo just popped up.

it knew it was a colo. if you put in thecolo field first, you don't have a bigdrop-- let me go back. if what you entered isjust a colo, that's fine you don't have to enterany codes at all, ok? that's an optional field. but if you do putin a code first it's going to tellyou, yup, it reads it and knew that that was a colo procedure.

it'll show you some errorit'll give you if doesn't. in this example, the kpro knee arthroplasty fieldwas selected first and then the user entered27437 as the cpt code. and this was accepted without any alert. its like, "yup, you were right. that's a kpro." you entered that firstand then you said now i'm going to putin my cpt code.

you can choose either way. and it's like, "yup,that's a kpro procedure," because that is one of the ones we have loaded to say that's a cpt for a kpro. in this example the selective procedure code wascolo, you know, the ip who's everdoing your data entry said i'm going to put in a colo.

it was entered, and then thecode 0d190k4 was entered. as soon as that code wasentered and i can't even show it to you, icouldn't screenshot it, i kept trying because itjust like disappears. and it's gone andi'm like, "come on i've got to-- cani do something?" yeah, i could have iguess text boxed it in but it isn't what theapplication will do. it's showing you what theapplication is going to do.

if you put in a codethat is not in the colo group even though yousaid i want to put in a colo and here is thecode i think is a colo. if it's wrong, assoon as that code was entered, this alertmessage was displayed. so there are some kindof smart business rules built into this and itnotes that the code that was entered is not oneof the colo codes that we have in that spreadsheetthat i've shown you.

the alert notesthat-- and it even tells you, what is it telling you that code is that you've entered? yes, see that little sb? it's telling you that's a small bowel code. so i'm just saying,thank you to all those people in development whodid this for us, so. it's a good validationand it helps you know whether you're enteringsomething that's correct

or not. now in this example, the icd-10 pcs code 0rjrqj0zz was entered into the icd-10 pcs fieldfirst, they're based on codes. and as soon as this code was entered, it disappearedagain, gone. i know i entered i'mjust telling you i know what i entered ihave my little cheat sheet here.

just disappeared and thisalert was displayed. the code that wasentered is not found in any of the nhsnprocedure groups. now this could be somethingwhere you have a typo. or, it could be thatyou have entered-- let me see if ihave this in here. or no, i'm going to go back. i'm going to tell youbecause i can't remember if i put in here, i'msure it's coming

up so just-- i'll repeat myself later. it's really importantwhen they built the icd-10 codesthey did not ever, ever used the letter o.no o's are ever found in an icd-10 code andno i's are ever used. and i can't-- it'sbecause they don't want people to figureout is that a zero or the letter o or isthat a 1 or letter i. so again i'm going to saythis write it down big.

in icd-10 codesthere are no letter o's, there are no letter i's. there are only zerosand ones when you see something thatlooks like that. this is important becausei am seeing a lot of-- and i've beenguilty of it when i was getting usedto this, you know. and when you're readingthe code you can look and think, "oh,that's the letter o."

no. if you see it it's a zero. and that can give yousome error messages when you go to do that littlefind i was telling you. if you've put an o in it'll tell you, "this isn't anywhere," because it only reads zero, all right? so that can be a littlehelpful tip for you. now let's move on to this section. we haven't done a lot of changes

to the procedure details, we have our wound classis listed here and wound class is an assessmentof the likelihood of contamination at thetime of the procedure. and the reason i putthis up here is it's really importantto realize. this should be assignedby a person who is really directly involvedin that procedure and knew the intimatedetails of that procedure.

this is not something an ip is assigning. it should be-- it's assigned in the or. and the reason that isay this there's a little time you mighthave to change, and we'll get to that,is really-- it's really important that your orstaff is assigning these. and if you think you'rehaving issues it's just a really great teachingopportunity to work with them to try to educate them.

the other issue, the little last bullet is nhsn, we just-- and i don't want tomake it sound like it's rude when you getthese e-mails back but nhsn does notmake recommendations on wound assignments. sometimes people will send us a very specific case and say, "what do you think the woundclass should be for this?"

or they'll send us areally general this type of procedure what shouldthe wound class be. and we just don'tgo there because it's not appropriate for us. it really is basedon the wound class and on what was thefinding of that-- the definition ofa wound class and what was found inthat specific case. we already kind ofdealt with inpatient

and outpatient when we looked at the definitions so that didn't change. i do want to note becausethis came up a little bit. so for outpatient procedureswe do-- when you look-- let's say you'rean asc and we did load all of the codes they are-- you know, for cptnow because they only have a littlebit because a lot of ascs use cpt codes not icd codes.

so all the-- of our nhsnoperative procedures have cpt mapping andicd-10 mapping now. but for those of you thatare ascs and it's something we'll look at in thefuture not for 17. ascs don't have-- ifyou are selecting that you're documenting anoutpatient procedure, you're saying yes, becauseyou're following something. you don't have thefull gambit of every operativeprocedure available.

if you try to enter a cabg being done as an outpatient, it-- you're going to get an error message that that proceduredoes not match the location for outpatients. so just a reminderthat outpatient procedures when you select yes, you could get an errormessage if you enter one of those that isn'tavailable in the idm

as being something we wouldexpect could be that. and again that'ssomething to just make sure your data is clean. it could be just amistake, "oops i didn't mean to select outpatient that was supposed to be,you know, outpatient no", so. your duration isyour procedure start time, procedure finish time we didn't change those definitions at all.

this is the wound class. i knew i got to it more. so this is a situationwhere there could be an example where an ip has tochange a wound class or has to have a conversation with the or. we had a big-- it's now several years ago. we had an ssi workinggroup and they worked hard on a lotof these changes. that's why we have bmi now.

that's why, we-- you know,we have diabetes now. all this came outof a hicpac working group for a surgicalsite infection. so what they did--we decided to do in the applicationit has this subset and these are theonly ones that i have listed here, yourappys, your bilis, your gallbladder procedures,colo, rectal, small bowel and vag-hys thatare on the drop-down

in the applicationdo not have clean as an option it'sjust not there. because these couldnever really be defined as coming anywhere close to meeting a clean definition. so those are the only ones. so when people send mewound class questions, pretty much what you'regoing to get is based on what they found inthe or, any, you know,

use that wound classexcept in this case if your finding anyof those highlighted in yellow comingacross as clean. you're going tohave to, you can't enter it, you have to upgrade it to at least cleancontaminated and your wound class and then have aconversation with your or liaison or who you work with, you know, all of us ips havesomeone who's our

buddy in the or thatwe worked with. you're going to have to have a conversation to say, you know, "i'm not allowed to call these clean and i have to change them when they're coming across like that." so, you know, this is goingway back historically but as in the past therehad been some, you know, verbiage fromus that, you know,

a csec or a hyst or ovary,you know, can't be cleaned. well, that's actuallyno longer true and that was not felt tobe true by this team that put together the groupthat can't be clean. so there could be c-section,hyst and ovary procedures that a surgeon does determineare clean procedure. will they all be? no, but they candetermine them and you won't get an error message.

trauma field, this is again one of the fields that will be, you know, investigated with all our risk adjustment. if this operation was donebecause of a recent blunt or penetrating trauma, you'regoing to select yes. if the bowel isnicked or perforated during an operative procedure, that doesn't turn thatinto a trauma case, ok. when we do get that it's like,

"yeah we did something sort of traumatic, it's like yeah you sure did." but you don't get tocall this a trauma case now and helpyour little sir, so you got a little bigger issue you might need to report, but. so i just want toclear that up because it is a valid questionto ask, you know, but the answer would be no on that one.

a big fall down a set of stairs and you've got a fractured hip? yes. and what we're talking about is like immediate trauma. we're not talking aboutsomeone who, a year ago fractured their hipand has been having in a trauma and has been having problems with it andkeeps going back to the or and working with that hip.

no. it was the firstor procedure when the trauma had occurredthat's the trauma yes, not ongoing repair of a past trauma, ok? i had someone, youknow, where they had had the procedure performed and then six weeks latercomes back for part two of it. no, that-- the partone was trauma equals yes but not-- it doesn'tcarry on forever. scope, they check yes if the nhsn--

operative procedurewas a laparoscopic procedure performedusing a laparoscopic or robotic assisted, alot of this you'll come across is a robotic assisted procedure otherwise check no. we remove-- we-- this isnow a year old, i could probably take this offbut there used to be that reporting instructionwe took it away last year that said if theyextend the trocar site

for like a hand assist or to put a little port thing in there, you have to like do scope equals no now. well that's just too labor intense. its like, really, we'regoing to have every ip open up every singlelaparoscopic procedure that comes across asthis is a laparoscopic procedure and say,"let me read this." it was too intense so wesimplified it if it's--

you know, if it says it'sa laparoscopic procedure. but what's interesting, we'llget to a little later is that there's a way youcan use your codes to read whether it'sa scope procedure or not if you'reusing icd-10 and we'll get to thatin a little bit. the only time thatyou do put scope equals yes, we stillhave left this in is when you do a cbgb,cabg with a chest

incision and a leg harvest site, you do put scope equalsyes for that to donate-- to let us know that the leg was done via a scope approach. that's just a tiny report. and that's in the application. so here's my kind ofexciting-- i could define myself almost as an icd-10nerd at this point. i wish, not something i'm proud of, but.

what's interesting, i'mgiving you a little mini lesson here, how many ofyou have been really-- are trying to figure out what this mean? it was like, i washanded these course months ago, monthsago, it was like-- it's like reading a foreign language. i didn't know what i was looking at. its like, "oh, this is greek to me." have-- can i just see alittle show of hands,

how many of you havebeen trying to figure out what they meanand no judgment here because i barely havebeen-- yeah, a handful. so one of the key codes that we worked with a lot that was one of our early codes we learnedabout is the fifth. i'm going to call it thefifth place position. see that fifth position there? that position inevery icd-9 code

tells you the approachthat was used for that operative procedure, all right? and this could be reallyhelpful, this fifth character. so if the fifth characteris a zero that tells you that wasan open procedure. zero means open, ok? so what we did inthe application, we made this scope field. so now, i'm showinga picture of the

actual applicationversus the form. for those of youthat don't play in the application,we made it so that if you have enteredthe code, again it's not a required field,but if you have it-- the fourth-- when you see a 4 in that position, thatmeans a scope-- perc endoscopic approach, perc endoscopic. they went through the skinwith a laparoscope, ok?

so what we have the application do is default toscope equals yes when you put something that has a 4 in. it doesn't mean you can't change it. we did not lock that in. you could switchthat to no if you're looking at a setof codes and said, "oh yeah, they gave me this code. there's a 4 but ican see they switch

it completely toan open procedure and i now have a scope with a field that has a zero in it." you could change it. but i thought that wasnice-- a little nice touch that we coulddo that this time. so here's one that showsicd-- a colo code, the fifth position,what's sitting there? not an o, a zero.

ok. and it will default to scope equals no when it reads zero. so, it was a littlebit of trying to make a little bitof intelligence into our codes, a littlesmarter application. all righty. and again, it canbe edited if that isn't what you feel is correct. now there's a fewgroups that have

some additional required fields. there's five proceduresfor which there are additional risk factorsyou have to put in, c-section, fusion, hpros and kpros. for fusions you have totell the spinal level and you have to tell theapproach and that's where i snagged thatlittle screenshot, again, under supporting materialswe've given you some fusion, icd-10pcs code guidance.

because those codestell you this was an anterior-built. i'm not going to give youthe lesson of the codes for what's an anterior,what's a posterior. but we have a cheatsheet that we built for you that's goingto tell you-- help you with that if these have a fusion code in front of you. now for kpro and hproprocedures, can i

see a little show ofhands to how many of you follow those i knowit's a large amount, yeah. over 50% have raisedtheir hands in the room. there are these fields. there's a new field thatsee the very second line, i have a bluearrow going there. that's a new field. it's a field to show that asupplemental code was used. it isn't a-- there's no asterisk.

we start the asterisk underneath it. that's not a requiredfield and the supplemental codes arenot hpro and kpro codes. there are list of codes,if you go into the hpro and kpro group, thattell you they removed or something from thehip and then replace something from the hip,so they are your hint that a revision isprobably been done to the hip or kneeversus a primary.

because they had to take out an old hip or take out something and then they're putting in a new one. so, the new fields, all thecodes that are associated-- also for those, wasthere a prior infection at that joint in thelast 90 day period, that also we gave you new codes to help answer that question. a lot of those arediagnosis codes and that

has its own supportingmaterials as well. and there is wherei've got a screenshot of the guidance for your hpro and kpro procedure detailsand for your prior infection at joints and your fusion are there, ok? i do want to tell youthat for icd-10, we are going to doanother update. we do know there are some issues. if you find issues,i'm not going

to deal in question and answer with specific icd-10code questions that's kind of likeanswering a case. i can't answer thoseunless i have my new icd-10 book that'sthat big, you know. for any of you thathave that on your desk or have beentalking to your coders, so but i will addressthere are some issues. there are some codesthat will need to be

removed, maybe added andthat update we will-- we'll get and we're workingfuriously on that update and we'll also be probablygiving you an update of those supplementalcodes for hpros and kpros to try to make the work asclear as we can be, you know. we really knew this wasgoing to be in flux for a while until thingskind of settle down and i'm hoping withthis next update which we don'thave an exact date

for the next dateupdate for codes so i'm going to say, latespring-ish, you know. it depends what partof country you're in, late spring forminnesota, not florida. no. i don't [laughing]. i'll pick the middle of the country, latespring in virginia. so-- but we are awarethere are some issues and if youfind any issues,

they've been hugely helpful for us. i'm going to give an example though. i'm going to give two examples, ok. and then i can stay,you know, at the end of the second presentationwith questions. but there is some concernabout how coders were instructed to code--abdominal hysterectomies. there are right nowcurrently only two codes that when we use theofficial mapping guidance,

that map 9 to 10 forhysterectomies only two codes mapped as true abdominalhysterectomies. it's the only code groupthat got smaller versus colo that, you know,went from 30 to 200. so, i'm just tellingyou though there has been some questions that-- and we don't knowyet if it's coders who got different instructions. we've been told that,you know, they're maybe

coding it via route ofremoval from the body versus how theuterus was detached from its supporting structures which is traditionallyhow coders have always coded with icd-9. but those are the twocodes so if you're using those. if you're clearlyseeing that your-- i don't even want to go there. if you're clearly seeing, for instance,

we know there aresome missing fusion codes, all right, we know that. if you're seeing full blowfusions being done at your facility and thecode isn't on the list, again these codes are not required fields. please put those fusionsinto your denominator data. you know, we're going to fix that. we're going to get those fusions that are missing in there.

but, you know, wewant your denominator data to be as good as it can be. and because those--that field isn't required, you have theability to just put-- it's a fusion case, asthe procedure name, ok? so in summary, you'regoing to complete and enter adenominator procedure for every procedure andthen you're going to use the ssi protocol,those wonderful table

of instructions andkey terms to help you do this asaccurately as possible. so, hang in there, getting close. with this transition,i was hoping i'd be a tiny bit further along. i may have to be even moremotormouth in the next time. it's-- we're going to move into we do-- you know, i'm going tojust like somebody else i'm going to use everylittle five minutes

because it's such a-- early lunch. so let's see if we canfinish superficial incisional in thenext five minutes and then we'll break, youknow, at 11 for lunch. now, again there are very few changes to theactual definitions but there was a tiny tweakto superficial incisional. and it's kind of subtlebut what we realized is so criterion a,is that the same?

yup. so it's alwaysbeen purulent drainage from thesuperficial incision. criterion b nowhas that expanded verbiage we use toaccount for some of the other tests and this did happen. this has happened. we have had somewounds, not a lot, but there may bemore than i know. but in terms of questionslast year we have

some wounds that theydid pcr test on them in wound clinics and found mrsa via pcr. it was flat out, yup it's pcr and it's mrsa. well, we couldn't reallyuse that last year. but this year, ifthat's what you have, it would meet criteria because it's a wound culture,it's pcr and it's mrsa. i don't think a lot of peopleare doing but we're trying to stay ahead of the curve there, ok.

so these areaseptically-obtained organisms, our faq defines what is anaseptically-obtained culture. then you get to see, andthis is where we changed it. what we realize whenwe really again looked in detail at criterionc, criterion c said, you have a patient, they've got symptoms. the physician deliberatelyopened the incision. you've got an actualsurgeon there, usually maybe, and theyobtained a culture.

well, that is certainly anaseptically-obtained culture. so it's like, "oh." now it's an aseptically-obtained culture, but we're telling they haveto have two symptoms, so no. so if a superficialincision is deliberately opened by a surgeon or attending or other designee,and we have that defined in the definition,and a culture or nondiagnosticculture-based testing is not

performed and the patienthas at least one of the following symptoms listed here, that's goingto meet criteria. so this is where thesurgeon is choosing to open a symptomatic patientwho has an incision and it is where they'redeliberately opened. this is not spontaneous dehiscence. that's not a mistake. we don't account aspontaneous dehiscence

in this criterion c.it would not meet. so that's why we changed that. so this is where theychoose not to perform. and then our last oneit didn't change, diagnosis of a superficialincisional ssi by a surgeon, attending or other designee. now, i want to--these are couple of our reporting instructions. they didn't really change.

i do want to notethat that diagnosis of treatment, if it's really-- i'm just saying, it's just a cellulitis. the physician sayscellulitis or the physician throws some antibioticson for a red, warm you know, incision orthe surgeon throws it on for some swellingjust by itself. that's not criterion d.but if the physician is seeing this incision,seeing what's going on,

putting the antibioticsin and calling it a surgical site infection,well that would be. the cellulitis iswe're saying when it's truly just thatand they're not-- they're not having anymention that they are calling this is surgicalsite infection. a stitch abscess alone isnot considered an ssi. now, when we talk aboutstitch abscess, we really put that inparenthesis what it means.

we're not talkingabout-- i've had people that wantedto call a stitch-- not call a pji becauseit's a stitch abscess. no, no, no. this lives just in our superficialssi definition. we're talking where the incision kind of-- the stitch enters theskin and they get these little tinypustule thing just at the site of the incision.

that's what we're talking about. not something thatprogress-- i don't-- if even it started as thatand then progresses into a deep incisionalssi, that meets criteria. localized stab wound or pin site infections, those againare not considered to meet surgical site infectioncriteria or soft tissue. but our laparoscopictrocar sites are-- not-- they're part of your incisionsthey're not a stab wound.

stab wounds we meanwhen they make a stab wound toput on a jp drain or something aside of the incision. again, if multiple levelsare involved, the type of ssi, report the deepestlevel that's involved. so if you startedwith skin and it's-- it meets deep incisionaland it meets-- it started superficial andthen meets deep incisional within the surveillance period,

you'll do at the deepest level. so i'm going to givethree little quick updates based onquestions folks asked that they grabbed me beforei went to lunch, ok? so welcome back everybody. welcome back tothose of you that are watching viaour web streaming. one of the things i wantedto tell you that when we get in the maybe latespring our next set

of code update, weare going to have a descriptor next to every code. we really need it with this. we didn't seem tostruggle with it with icd-9 but whereyou see you'll-- every code will have itsown unique descriptors. you can kind of look andgo, "oh, well that's a resection of the, you know,cecum or something." so that'll be a big update and

that'll be true foricd-10 and cpt. i also wanted to letyou know i have been pointing out more than once that supplementalmapping that we offer you all if you do hipsand knees for how to tell, fill in those procedure details. i have one in draftformat completed if you're using cpt codes. they are so much easier.

i have a table built. i have shared it withsome folks in draft so if you feel likeyou were trying to code the detailsfor your hips and knees using cpt, sendan e-mail to nhsn, you can say for janet if you want. and i'll-- i have been sharing the draft it's like we're-- it's 90% there andwe'll then are working

on getting it uploadedand again may-- to the supplemental materials in ssi, ok. and then the lastone, someone asked and i may haveglossed over this. again, the rules didn'tchange because we went to icd-10s but ifthey do a procedure and you get a line listand someone went to the or and you find thatthere are three distinct or two distinct colocodes coming for the

procedure it does notmean you put in two colos and no it's the samerule we always had, you'll find thatreporting instruction. i really like to emphasize, you know, ssis aren't the simplest and there are a lot of twosections in the protocol. there's a numeratorreporting instruction and a denominatorreporting instruction. it's almost like your ownlittle faq there and --

that instruction lives in our denominator reportinginstruction. if you take a person to an or and do-- and you have more than one code from the same procedure group like there's two colocodes when they came out. it's still one colo, youdon't enter it twice. and that didn't changewith the switch to 10. all right, let's jump backon where we left off.

this is table 2. because we lost table1 all our tables got shifted to a littlebit lower number. this is a table thatshows which procedures have a 30 daysurveillance period where day1 is the day ofthe operative procedure and which have a 90 daysurveillance period. but i have a little flag there. you have to rememberthat that 90 day

surveillance period isonly for deep incisional and organ space ssisand i do get questions where someone is saying, "i'mgetting an error message. it says that this doesn'tmeet for the definition, i know it does." and ialways answer first if i don't get thedetail are you trying to enter a superficialmaybe infection of a knee on day 40, that theapplication is smart and it knows that if you're trying

to enter a superficialinfection beyond 30 days you'll getan error message. so if you see at the bottomin yellow i highlighted. superficial incisionalssis are only followed for 30 dayfor all procedures. so look at this whole listhas 30 days for superficial and the 90 daysurveillance period is for deep incisional andorgan space ssis. this is our definition,didn't change,

of a sip or a sis,if you call it, your superficialincisional primary and your superficialincisional secondary. these are not availablefor all procedures. if it is a procedurethat has a ability to have a secondary sitelike a leg harvest site after a cabg or atram flap site after a breast procedure then you'll-- if you open up andsay you're doing a

breast you'll seethat option there. it's not available for everyone. let's do a case. this is more case heavyin our second half. its 2/18 you have a 65year old female admitted and had a laparoscopic left hemicolectomy which is a colo. there was no evidenceof infection noted at the time of surgery.

three trocar siteswere closed and the fourth was leftopen and packed. on 2/24 purulent drainageshe comes back and it's noted that oneof the trocar sites. a culture is obtainedand it is positive for enterobacter species and e.coli and the patient is started on antibiotics. is this procedure aprimarily closed procedure? yes-- number one yes, number two

no and the polling is open. i got people voting already. coming in prettyquickly here, i'll give you about 10 more seconds. here we go. and the answer is yes. very good, but let's look at the no's. remember, rationale,if there are multiple incisionsand again this is--

you will find thisreporting instruction in your ssi reportinginstructions. if there are multiple incisions and if one of them is primarilyclosed it is considered a primarily closedprocedure, ok? what should be reported to nhsn? nothing. the surgeondid not open the wound, so the criteriaare not met, again, nothing but for a different reason.

it is an hai but it's not an ssi. a superficial-- an ssi superficialincisional primary. an ssi superficial--deep incisional primary. everyone is voting pretty quickly, about 10 more seconds. and very good. the answer, that's correct. it's a superficialincisional primary infection and we'll goover why that is true.

here is the rationaleso you've got your superficialdefinition here. it occurred within 30 days. it was at that trocar site. there was no mention that theyopened up and went deeper. it was just some pus at atrocar cell or trocar site and your trocar sites arepart of your incisions. and that purulent drainage from that-- so you've hitit right there.

ok? that makes sense. and this one, theyalso-- they did not deliberatelyopened that one. i think that's amistake that there's a check mark there so iapologize for that. all right, let's do case 6, another one. this is a 70 year oldmale who's admitted and underwent ahemi-colectomy and repair of an abdominalwall hernia via the

same incision on theday of admission. the incision was closed and a jp drain was placedvia a stab wound in the left lower quadrant. and then the patient was there four days and then discharged. they came back aboutthree days later to the ed with a red,painful incision and the incision is draining

yellow foul smelling discharge from the superficial incision. the physician removes twostaples, probes the wound. the fascia isintact and only the subcutaneous tissue s involved. no cultures were obtained. antibiotics were ordered,the wound was packed and the patient wasdischarged home from the ed. so what should be reported to nhsn?

nothing, a wound culture was not obtained, so criteriaare not met. nothing, he had twoprocedures performed so you don't know which onecaused the infection. yeah, so you just geta big old buy, right? or, an ssi superficialincisional primary attributable to the colo or an ssi deepincisional primary attributable to thehernia repair.

so, let's get your voting going there. i feel some discussion going on. i'll give you about 10 more seconds. very good, look at that, 93% of you. excellent. you're not too sleepy from lunch. here's the rationale. are you ready? remember, if morethan one operation

is done through asingle incision, you have-- you know, you're in this chart. it's not like this issomething you're-- you know, you haveto be looking, delving into this sort of situation. first you're going to attempt to determine the procedures thought to be associated with the infection. is there somethingreally logical

that tells you whatit's related to? an example, if a patienthad a cbgc, you know, and had a card proceduredone at the same time, like a valve, anddevelops an infected valve, well you're going to-- that ssi will be attributedto the card procedure, not the cabg because it's very clear which one it points to. if it's not clearand think about

this, how would it ever be clear with a superficialincisional or even deep incisional for that matterwith two procedures that happen in thedeep abdominal space which one is it related to? so for that situation, wehave our table 4 which has based on informationthat we analyze, we redid this about,gosh it must be three or four years ago and i thinkit's probably going

to be redone withour re-baselining, you know, because we're going to be looking at all thenew risk adjustment. which are those proceduresis the highest risk? and colo is definitelyhigher risk than hernia on this chart, ok. so that's why it was attributed to the actual colo procedure. so let's move on,now we're talking

deep incisional,we've moved down, you can see the deep incisional layer, we justfinished superficial. there were absolutelyno changes in this definition thisyear, whatsoever. so i'll hit it quicklybut this is where you've actually moved to thelevel that you know that the fascia isinvolved and that last case, rememberthe physician probed

and the fascia was intact,that's really what they're looking for,that's very important. it's a big differenceif a surgeon is going to be trying to treatsomething that's moved into the fascia musclelayer versus superficial. and when you see that fascia is intact, they're telling you we-- you know, we dodgedthat bullet it is still at thesuperficial level.

but when you get todeep incisional, the incision stillwasn't involved but it's of the fascia muscle level. again 30 or 90 days, i have both there, because now you remember deep incisional can befollowed for 90 days. and the patient haspurulent drainage from deep incision and b is verymuch like criterion c for superficial, they kindof mirror each other.

but for deep incisional,it can be for incision that'sspontaneously dehiscences or is deliberately opened by the surgeon. and for this one, again thenthey do obtain a culture or they chose not toobtain any culture at all. so we did still leavethe culture, the culture is obtainedand it's positive, or they chose to notculture and in this one again, you have to havea symptomatic patient,

see that and, and youhave to have fever or pain or tendernessand a culture that they did do a culturebut it was negative. you don't-- can't applythat to this criteria. so it's, you wouldn'tuse criterion b for a negative culture whenthey open the wound. and then the lastone is an abscess and this is a sortof general one but it is kind of the lowest on the list.

but an abscess or otherabrasions or infection involved in the deepincision that is detected on gross anatomical or histopathicexam or imaging test. so this is where they-- anyof those can meet this. i don't see it appliedtons but it's definitely there andwhat i want to point out here is the definitionof gross anatomical exam. this is the locationof the infection as well as the nhsninfection criterion

that you're applyingwill determine if that exam must involve aninvasive procedure. so think about that. you know, if you'retrying to diagnose invasive procedure reallydeep in the pelvis or something, you'regoing to have to do something to really beable to confirm it. for example, a grossanatomical exam of an intraabdominal abscesswill require some sort

of invasive procedurewhether it's a ct guided drainageof the abscess where you're seeingthe pus coming out or they've taken themback to the or, that's what we mean bygross anatomical on that. however, criterionfor example for a urinary system infectionincludes this and it might be a patientthat has abscess or infection on gross anatomical orhistopathological exam.

and that one, you--since the urethra is one of the locationsand symptoms there, you could just see pus comingout of the urethra, for usi and it didn't need an invasive procedureit's right there. what i want topoint out for this because i do getthis quite a bit, especially after c-sectionsand after hysterectomies. if a woman comes intothe er and she is

like febrile and hasacute tenderness after a c-section andthat is on physical exam and that is like a redflag, tender abdomen, maybe a fever, maybesome dysuria going on. to then, that is a grossanatomical exam of a fresh c-section patientor hyst patient, that is enough tomeet criterion c for organ space, where we'regoing to get to that. you do want to move on and see

if they meet something more. so a gross anatomicalreally depends on the criteriayou're looking at of where you-- if you need to move further. we'll talk about it more whenwe talk about organ space. deep incisional primary and deep incisional secondary,again we just-- it's again the fact thatyou can have either a primary or secondarydepending on the site.

what's going on here? hold on. i'm sure it's-- there we go. ok. so case 5, this is--let me get you down there. what's going on? i-- oops, i know what's going on, sorry. there we go. case 7, this is apatient who's admitted to the hospital forelective surgery

and active mrsa nares screeningtest is positive. the patient undergoesa total abdominal hysterectomy and no evidence of infection is seen atthe time of surgery. then on 3-15, they're discharged they had no problemsat that point. and then on the18th, the patient is readmitted with complains of acute incisional painsince the day before.

the surgeon removes twostaples, opens the wound and notes that thefascia is not intact and sends a specimen from the deep wound. the culture results returnand are positive for mrsa, the patient spikesa temp five days later and blood cultures are obtained which come backpositive for mrsa. is this an ssi? yes, it meetscriteria or no, the

patient was colonized with mrsa, so this should be just considered poa. ok. yeah, yeah whichgreen one you can use? that's what happens, yeah. we're good. five seconds. great. really good. one of your higher scoresand the answer is yes. very good.

now the reason, remembera patient that is colonized with somethingwhen they come in, is no sort of exclusion forthem meeting criteria. and in fact, even thedouble whammy, is poa doesn't apply anyway, but this was just colonization. and in fact, colonization,a colonized patient can move on to then have aninfection of some sort to anywhere, blood,ssis, whatever, but

it doesn't mean youdon't report that. what infection should bereported in this case, a superficial incisionalprimary, a secondary-- a superficial incisional secondary, deepincisional primary, deep incisional secondaryor an organ space ssi iab. all right, you guys are so fast. we'll, finish up in about five seconds. correct. deep incisional primary.

let's take this apart. look at the definition. it's in-- it was withinthe 30 days for this. now, remember, withthis, it says 30 or 90 here but you're onlyapplying the 90 days for procedures inthe 90 day group and this was not, it's a 30 day. and the patient hada deep incision that was deliberately opened

by the attending andorganism was identified. and they came in withpain and tenderness, ok? so, it met deep incisional. does this patient have a secondary bsi? so go back and do a littlelooking at the dates and see if you think thispatient meets criteria for a secondary bsiattributable to that ssi. ten more seconds. fantastic.

yes. and let's look at that. so, there was your dateof event for the ssi. it's a deep incisional primary with mrsa. then blood culturescome back positive on the 20th matching pathogens. there's your important point there. there is that slide ishowed before your 3 days, 13 daysafter, so very good. now let's change this scenario.

i take this one and kindof keep the bones there so you don't have torethink the entire thing, but kind of switch it up a little bit. so it's saying this patient comes in for elective surgery, active mrsa naresscreening cultures, undergo a total abdominal hyst. no infection presentat the time of the surgery, dischargedon the 15th.

come in on the 18th withcomplaints of acute incisional pain sincethe day before. wound and clear serousdrainage is noted. the fascia was not intact. and they sent a specimenfrom the deep wound. cultures are final negative and no growth. and this is all theinformation you have, ok? this is what you got to look at. what infection should be reported?

a superficialincisional primary, deep incisional primary, some sort of organ spaceinfection or nothing because it doesn'tmeet ssi criteria. there is still quite a bit of discussion. but i'll give you about 10more seconds to finish up. good. this one is a little tricky but most of you got this. we'll look at it with thedefinition in front of us.

so, that was met. and that was met. but they didn't-- oops, i went too fast. they didn't have pusfrom the deep incision. they did deliberately open it. but it was culturenegative, you know, and you're not allowed toeven apply that criteria because it was clear drainageit was culture negative. so, that doesn't meet.

now, if i had put somethingelse in the case, now, i can kind of guaranteeyou clear drainage that surgeons arenot going to say, "oh, i think theyhave it," you know. they're usually reluctant to overcall. but, you know, ifthere was something more that the surgeonhad in their notes or some other evidencebeside what i just shared, there's apossibility you could look

at c but at this point--i mean, criterion c but it didn'tmeet at this point. now we move to thedeepest level, one of my favorites,organ space ssi. now-- this, we did not changethis definition at all either exceptthroughout all of these, where we would justsay, organisms were obtained from a culture.

we now have that wording about or a nonculture diagnostic. and i made those kind of little in this so that i could fit-- not have this slide tobe ridiculously wordy. but again, an organ spacessi can occur within 30 or 90 depending on thesurveillance period, involve any part ofthe body deeper than that fascial musclelayer you're now

in an organ spacethat is opened or manipulated during theoperative procedure and has at least oneof the following, purulent drainage froma drain that's placed into the organ space,so that covers, you know, closedsuction drainage, t tube drainage, ct guide drainage. and this can include,because i do get asked this, ifthey, you know,

put in asepticallyplaced drain into the patient at the timethey went to the or, and there is pus comingout of that drain three days later,you can use that. that drainage-- pus coming out of their intraabdominal space where the drain is placed,is would meet this criteria. it's certainly a redflag that you better start looking, andsee what's going on.

i think-- and/or see anabscess or other evident infection involving theorgan space is detected on gross anatomical, histopath or imaging. and, for all of these,the big and is, it also has to meet atleast one criterion for a site specificinfection in table 3, ok? that-- this and goes to all of these. this is what i call-- theway i like to talk about is, this is your general organ space

definition from the ssi chapter. but when you're dealingwith organ space, and i had this question lastweek, someone said, "i can't find theword organ space in the drop-down inthe application." you'll never see the word organ space. what you'll see is thedifferent organ spaces that you can use for thatparticular definition. and i think that's helpful.

and we have a new handy dandytool for you for that. so, two different criteria have to be met when you're dealing with what you think isan organ space, that ssi organ space criteriaand then you move in to what i finallycall chapter 17 and find the site specificcriterion that it meets. and it won't always meet. and i'll give some examples.

you can have a red flag of let's go look. but then, when you actually looked, no, this doesn't really meet any of the organ space definitions. so, i showed here whatthe form looks like. and if you think ofwhat the general organ space definitionlooks like, these are different thingsyou could have selected. i've picked all of them, you know.

you could have apositive culture from that drain in theabdomen or drainage or an abscess imaging,other evidence on gross invasive, grossanatomic histo. and that imaging testis over to the right. what will happen is if-- here, let me-- i'll go on to this. so, i'm going to hit that later. so, you're-- no i'm not, i'mgoing to hit it here, sorry.

let me go back to this slide. what's going to happen, i'm going to give an example here. if you have a-- let's say,a hip pji and the way you're meeting it is youhave a sinus tract. if that's all you select and try to enter it intonhsn application, you'll get an error messagebecause you haven't selected one of thecriteria from here

that told you, "oh, i'm goingto go now look at pji." and often it may justbe that other evidence of infection found on,you know, whatever. but the applicationis built that for every organ spaceyou are entering, you have to at least have one of these boxes appropriately picked and the specific criteriafor that organ space. and that is what sometimesgives you a message.

its like, "no, i think it meets." and i say, "go pick one morebox and it'll work." so the specific sites ofinfection that can be used for different organ spacessis are listed in table 3. it's not every definition in chapter-- you know,17, obviously. but all the ones listed here could be found attributable to some procedure as an organ space ssi.

and i'm going to give kudos to henrietta. i don't know how many of you have met her. she's also my partnerin crime with icd-10 codes and hipand knee codes, but. i had had this ideain my head for quite a while but nevermade it happen. so we built this, this year. this is calledappendix 1 and it's

in the back of the ssi protocol. it takes every procedure andit's basically showing you, if you were in the application what you have available for you. so let's look at triple a.for triple a, you could have a deepincisional primary, your organ spacefor that is a card or a git or an iabor a vascular. those are the-- so youcan tell without, you

know, having to actuallyopen the application. well, i have, you know, an appy. am i allowed to use orep with appy? if you've had an appy,the only ones available are the git organ spacedefinition and the iab. so i think this is reallyhelpful and you can-- it's a handy little tool when you're trying to figure it out. so that's why when you'rein the application

and you do your drop-downto tell what kind of infection you're entering, you'll never see organ space. you'll be telling it whichorgan space you're meeting. does that make sense? so this is a numerator reporting instruction number 2of attributing an ssi to an nhsn procedurewhen there is evidence of infection at thetime of procedure.

and this is just like putting it front and centerwhen you, maybe, have a surgeon who's upsetor an administrator. but, wait, thisinfection was there when they took him to surgery. do i really have to still attribute it? poa doesn't apply tossis if there's evidence of infection at thetime of the procedure. and then later in thesurveillance period,

the patient developsan infection that meets the nhsnssi criteria, it is attributed to procedure. a high wound class isnot an exclusion for a patient later meetingcriteria for an ssi. and if it really didmeet at the same level, that event maylikely be a patos but that's what we're telling them. so here is an example.

on 2/1, a patientpresents to the ed with acute abdominal pain,is admitted to the or the same day for a colon resection. there was a peritonealabscess noted at the time of surgery and abdominalabscesses were drained and a thorough abdominalwashout was performed. the incision wasloosely closed with some packing between the staples and a jp drain is placedin an adjacent stab wound.

the patient was discharged on the fourth. the wounds were healing well. they came back to the edwith fever, abdominal pain. they were sent to ct for a ct guided drainage of an abscess which when they culturedwas positive for e. coli. this is reported asan ssi-iab, it meets iab criterion 1, abscess thatis culture positive. and the patos field wouldbe selected as a yes.

now, what about--this is another reporting instruction found in our numerator reporting instruction. ssis followinginvasive manipulation or accession of theoperative site. now, the two mostcommon scenarios we see with this are patients who have shunts, ventricular shunts. and they put in theshunts and then those

shunts have to beregularly accessed. and they're draining csf from them. they are drawing inand accessing them daily possibly foreven sending cultures and then they've been doing this. and then suddenlyyou actually meet criteria, a positivecsf culture pops up. that would not beattributable back to the ventricularshunt procedure

because you've been reallyaccessing-- directly accessing that csf viathe shunts. so that's an example. another common example is breast expanders, they do abreast procedure. and then, they start goingto their physician's office and they're accessingand putting fluid into the expanders and lots of chance that they could possibly have

introduced something that way. so if they've beenaccessing these expanders, you don't then jumpover all those invasive manipulations andsay this was a-- something that was happenedat the breast procedure. those are two most common ones. now, what if a patientwith an ssi had more than oneoperative procedure? so, if a patient has hadseveral nhsn operative

procedures prior to anssi, report the operation that is performedmost closely in time prior to theinfection date. this doesn't applybecause i already taught you guys the 24 hour rule when you have two proceduresdone within 24 hours. because, you obviously--it's almost like that second procedure isn't in your denominator data anyway, so.

a patient underwenta colo on 1/12, one week later, on the19th returns to the or for a hernia repairvia the same incision, you know, because mightas well unzip that, we can maybe go in and do the second one. and, then this ssi, he develops an incisional ssi on the 28. that ssi is attributedto that second procedure, thehernia not the colo.

i want to show thisto you, it's kind of hard to know exactlywhere it fits in. but, how many ofyou are familiar with the tennessee checklist? oh, not that many. so i want to tell you about this. this is not us. we have a really goodrelationship with the tennesseedepartment of health.

and i actually e-mailedthem because this is showing you last yearstennessee checklist, ok? they-- i spoke with themand they are thinking that the tennesseechecklists that are based on 2016 criteria wouldbe up in a couple weeks. and this is the link. you'll know they'relive if, you know, when you go to thatlink you'll see it. what they do isthey-- it's amazing,

they take every oneof our definitions and they take it apart like this. so this is our iab definition. and they haveinstructions, like, if you only have to checkoff the one box but for othercriteria you'll need to move down to the green box. they have a key for all of these. and they very-- they'recompletely based on

our chapter 17 as icall them definitions. so what's up there noware the-- are based on 2015 but '16 is comingin a couple weeks. these can be really helpful. i think they're greattraining tools for new ips or if there is aparticular definition you keep stumblingon a little bit. these are a really helpful tool, so i wanted to push those.

anybody here from tennessee? oh, ok, yeah, a couple hands up. thank you. so, they're probablyworking furiously on this. i don't know if-- oh,someone's nodding their head yesthey're just like. so, let's do another case. so on 3/10 a patient wasadmitted and underwent a hemi-colectomy dueto colon cancer

and the wound class was listedas clean contaminated. they come four days later. they have a temp of 38.7, abdominal pain. ultrasound shows what looks like an intraabdominal abscess. wouldn't we be lucky if it said that? yeah, no, it's like that or maybe a fluid collection or no. but anyway, we'regoing to pretend

they gave a really simple read. then, the next day, theytake him to the or based on this finding, foran i&d of the abscess and it's found to be due to an anastomotic leakthat's occurred. and the abscessspecimen is collected for culture,antibiotics are begun and that abscess culture comesback positive for e. coli. and then they'redischarged from the

hospital three dayslater on antibiotics. does this patient meet criteriafor an organ space ssi? yes or no? all right, about10 more seconds, seems like mostpeople have voted. it's the best yet. we got to 99. maybe we'll get to 100 on oneof these today, but anyway. if you did that i'd feel like too easy.

yes. and here isyour rationale, is that this meets the organ space. organisms are identified from an aseptically-obtainedfluid or culture. they also had anabscess or-- this is your general organspace criteria. i'm looking at that firstto see, should i go further. and they certainly had anabscess looking on imaging test so it's like, "yup, i need to go further."

and, now, you then go towhat site specific ssi? so you found that andyou're like, "oh, i think i need to see whatthis is," you know, because you're going to have to put that in the application. what kind of organ space is met or-- oops, i justgave you a hint. or is it a deep incisional primary? is it an ssi iab, that'sour intraabdominal?

is it ssi git, that'swhere it's in the gi tract? or, not an ssi becausethe infection was due to the complication ofthe anastomotic leak. i hope some of you, i knowin our instructions those that are via the webstreaming can pull this up. i know there wasinstruction that hopefully you wouldprint out chapter 17, all our hai definitionsbecause they get used for secondary bsi andthey're used for this.

but, you probably have themmemorized practically. i've got 10 more seconds and we'll see what everybody thinks. ok. i think we're good. let's see how you did on this one. yes, very good. that-- this could be--can throw some folks off especially maybe ifthey're a little bit new. they met iab criterion1 and we're going to

be taking apart the iabdefinition in detail because it was tweaked this year. they had organismsisolated from an abscess or purulent materials and that is the criterion1 of our iab definition. but what about that anastomotic leak, hey, thatdoesn't seem fair. but this is actuallyin our ssi faqs again, pushing thosea little bit.

an anastomotic leak orpostop complication may contribute to thedevelopment of an infection but without the surgeryfirst of all there wouldn't have beenan anastomotic leak. and if the patientmeets ssi criteria, it must be reported as such. and this i want to kindof point to the-- a very important reportinginstruction again in our numerator, youknow, you're looking

at an event, reportinginstruction. i should have itmemorized, maybe it's nine denise but it's the one thatreally addresses the fact that a patient canend up getting an ssi because of somethinglike they didn't follow their dischargeinstructions. or they -- we see a situations so,i had a knee replacement, i went swimming in a creeka week later, you know.

real case--confidential though i didn't tell you whereit was, you know. and they-- thesestill if they meet criteria, you dohave to attribute it because you can imagine the nightmare if everytime you found in the surveillanceperiod an infection that met criteria andthe surgeon wanted to call every patient andsay, "well, are you--

did you change that dressingon day two like i told you? did you do this like itold you on day three? did you do that?" and we see it happen andnot just even at your own facilities, you canhave patients that go to nursing homes andthey're discharged and just for whateverincontinence like, you know, the dressing got soaked with urine, now they have an ssi.

yeah, so we have areporting instruction that says, "yeah but it meets, so we do need toattribute it to this procedure that is inyour denominator data." so, why was this though not a git? a couple of you selected that. the gi tract is a specific site of an ssi. the abscess was in that justgeneral intraabdominal space and it was not involvingthe actual gi tract.

the git think of that word tract. that is focusing onthe organs of the gi tract, infections of theesophagus, you know, and actually is in-- youknow, it goes to the stomach. it still involved wehad one the other day when they, you know,the actual abscess was in the inner likewall of the wall of the actual colonitself, you know, it hadn't gone into the generalintraabdominal space.

so this was theright choice that you guys picked forthis infection. so, now, whose favorite definition? we do apply this a lot becausemost of us are applying-- following colos in our monthlysurveillance plan. we did very, verylittle changing of the iab of the definitions in chapter 17 but we did update this one. so iab, again, this ispointing to the fact

that it's anintraabdominal infection, not specified elsewhere, ok? so the things that arein that general space, you got your gallbladder,your bile ducts, your liver, they're all in that, ok? but it isn't the specificgi tract you wouldn't go for this, so that'sjust the definition of what is-- when do youapply this definition. we-- all we did hereon criterion 1 of

iab is we justclarified the wording because it was a little bit not as clear. does the organism have tobe, the patient have organisms cultured from an abscess or they have pus? no, this is a positiveculture based criterion. it's organismsfrom an abscess or organisms frompurulent material, so you've got a positiveculture of pus or purulent or an abscessfor criterion 1.

you know, not supercomplicated, it's your kind of most obvious one that'sin the intraabdominal space. all right, then this is theone we updated for this year. and this was againand i-- i think it's nice that peopleare sharing it and that's why wedon't want our users to be shy but wegot a lot of input particularly at the lastapic national conference that when we took awaylogical pathogen in 2015,

it was causing facilitiesto really what looked like they werehaving to report bloods that were related tointraabdominal abscesses when a surgeon madea choice to go in, saw this big abscessbut didn't culture it. they're like, "i'm goingto get everything." but they see infection,they don't culture it but you have the patientgrowing b. frag their blood. well when that-- when theytook away logical pathogen,

you couldn't really meetsecondary bsi up here. so what we did withcriterion 2, the way it read lastyear was just 2a. but now you have two choices to select for iab criterion two. you can say 2a or 2b. now, 2b i highlighted the and there. it's the same as abut then we say, and they have organismsidentified from blood

by a culture or non-cultureblah, blah, blah, blah, blah. the organisms identifiedin the blood must contain at least one ofthe following pathogens. so it isn't freerein, you know, you don't have staph epihere, you know. but you have what weselected for ease and because it works andit'll be easier for you because we have a list,this same set of pathogens is what weused for mbi pathogens.

so if you're not surewhat all this includes, you can go look inour pathogen list at the mbi pathogen, so makea little note of that. and a lot of you probablyhave those memorized. so this is where we'llgive some examples of it. so this is where ifthey went it, found a big abscess and ifyou've got b. frag in the blood, that's all you have. they took them to the or and this.

this you could say now thatthat blood is secondary and that you have ab. frag organ space iab. so hopefully that'llmake people happy and will help decreasesome of those bsis that we're really starting to have to be selected as primary when we know that's not reallywhat was going on. and this is criterion 3 which didn't really change at all.

it's still the same one. now, this is one-- rememberand this will help you as we start getting intotalking about blood. this is a definition,the iab where blood is an element in twodifferent places now. blood is an elementat this definition in 2b, that wejust-- the new one. and blood has alwaysbeen an element in criterion 3b whichwe'll talk about now.

that's where criterion 3ais-- now, 3a and we put some-- we clear this up in our reportinginstructions under iab. you know, the way i justtalked about criterion 1 where it's pus or purulencethat they cultured and that's criterion 1 you've got in this positive culture. 3a is for when youdon't know if it's pus. it could be serous, itcould be serosanguineous, but it's organisms thatare seen on gram stain

or drainage of tissue obtained during an invasive procedure or an aseptically placed drain. but it isn'tnecessarily an abscess or pus that they're draining. but it's positive, andbecause of that, this is kind of little lowerdown on evidence. if you're going toselect 3a, it's in a patient thathas two symptoms.

so, for criterion 3 you always have to start with the fact, can you find two symptomsfor this one first? then, if because you can'tfind that, you might as well-- you can'treally apply this one. two symptoms in a, sothere they maybe took them down for a ct guideddrainage and they talk about some serosanguineous fluid that they drained off, you know,

60 cc's and they culturedit and it grew b. frag. so that would be,you've got two symptoms and they got a positive culture. b would be a symptomaticpatient, again two symptoms and you haveorganisms identified from blood by a cultureor non-diagnostic test, it's that bloodculture test again, and an imaging test evidencesuggestive of infection. ok, so, its two symptomssuggestive imaging

test and a positiveblood culture. again, last yearit was just-- you could pick any blood you wanted, now we've given you the same subset, it doesn't make sense. so for this, we wantyou to be looking at pathogens that are moreexpected to be seen in and associated withthe intraabdominal gi area. the yellow part is wejust had a lot of people

asking, "what doesclinical correlations?" so you can get theseimaging test that are equivocal, itmight be abscess, it might be a fluid collection, we're not sure, it's equivocal. that's where we then saidthat if it's equivocal, it's supported byclinical correlation but we didn't likesay what that means. so this year we just added i.e.if

you've got physiciandocumentation that they haveantimicrobial treatment for an intraabdominal infection. they're saying,"no, i'm treating an intraabdominalinfection based on that ct finding, ok?" and that's important. so that, we wantedto clarify that so to maybe help youall and not have--

it would definitely--it cuts down on the questions ofwhat does this mean. and it's not that thephysician just says, "i'm treating thatb. frag in the blood." no. because whoknows what that's from or that e.coli in the blood. we wanted the physician to be documenting that they're saying because this is an equivocal

imaging test that we do think that this equivocaltest is pointing to an intraabdominal infection. and we did putthis definition in key terms so there it is again, just a reminder that we updatethe key terms for that. let's try another case. a patient had an abdominalhysterectomy on the 22nd, came back,it looks about a week

and a half later with pelvicpain and a temp of 38.4. they did a ct scan andit reveals an abscess fluid collection inthe deep pelvic area. the next day the surgeonopen-- took the patient in the or, theyopened the incision, drain dark purulent appearing fluid. they send the specimento the lab for culture and the physicians noted in the discharge note theythink its infected hematoma.

antibiotics begun and they, you know, close that incision. and when they got the results back from thatspecimen they send from the deep pelvicfluid collection abscess, it's pseudomonasaeruginosa. so, what should be reported in this case? an ssi iab, an ssiother reproductive, or an ssi vaginal cuff,

vcuf is when vaginal cuff-- is an organ space vaginal cuff. all right, about 10 seconds. yeah, so. this is why ihave this one in here. this is good. so the answer is what 53%of you got, ssi orep. kind of helping guideyou there when i was talking aboutwhat iab means and not otherwisespecified, you know,

nonspecific and here'sthe rationale. why isn't this an iab? remember the iab is wherethe intraabdominal tissue is-- if it's notspecified elsewhere. so here is now our orep definition. now if you look at what the orep definition is, be--and think about it. this is a really--this is where you kind of want to firststart thinking

after maybe hystprocedures-- not hyst, after c-sectionprocedures. any procedure thathappened that was down in the deep pelvic area,even a hyst as well. i mean, the uterus isn'tthere anymore but the infection after hyst canset up in that area. now i've got it underlined the key word is deep pelvic tissues. so when you're dealingwith an abscess or

infection that set up inthat deep pelvic area and that woman had had a hysterectomy. you need to be lookingkind of at the orep definition unless thatinfection was so massive that it spread out reallyinto both areas it's in the intraabdominal,it's in the deep pelvis, so this one-- that's why it meets this. they had organisms identifiedfrom that deep pelvic area. and this shows it can meet more than one.

this patient, you don't just sometimes meet one criterion. you-- this personhad the organisms when they took in the or. they had the abscessthat they saw, that was another evidenceand they-- so. we did a little changeto this one under criterion c thoseyellow words are new. patient has suspected infection

at the sites listed in orep. but we do tell you what thesites are up here, see? prostate, vagina, epididymis. but what was happeninga little bit and we got enough questionsthat we thought, let's kind of say this againbecause criterion 3, a patient only needs twosymptoms, ok, see that? two of these symptoms,fever, nausea, vomiting, pain or tenderness,

dysuria and if theyhave organisms cultured from the blood. so we had a couplefolks said, "well i've got a patientthat has some-- came in vomiting and a fever and a blood, can i call it orep?" we're like, "no, not unless they have some sort of infection in the reproductive area, you know?"

so we just want tokind of make it really clear that you applythat, those two symptoms in a positive blood or those two symptoms in a physician is treating other reproductive site for infection. let's do another case. you have 45 year old female undergoes an abdominalhysterectomy and a colectomy performedthrough the same incision.

if both theseprocedures are in your monthly reportingplan in january, which one or ones shouldyou enter into nhsn? both the hyst and colo are entered. we already kind of cover this earlier but they would both go in because they're bothin your reporting plan. i'm going to go backto that because when i've had theother question i was

thinking [inaudible]. i've had people say,"well they went down for a hyst but whenthey open the patient up they actuallyrealize they had to do a colo but iswasn't like planned. do i have to report that colo?" it is like, yes you do. they did-- the patientis going to wake up finding out theyhad a colo procedure

but it is still a colo andyou're following colos. it isn't just that you send down the primary thing they went down for is whatever happenedat that or situation. so your rationale onthis one is at different operative proceduresperformed during the same trip to the or, again,we've kind of seen this i'm not going tobelabor this, but. in some ways i pullall these words up

because these are allreporting instructions that you can find ona slow day where you can really go throughwith a highlighter and read all those-- yeah i know. that's just mean. i'm waiting for one of them too, so. and you'll see all thesereporting instructions so i do tend to eventhough i can kind of get like, "you got toomany words on that slide."

it's just to show you,i'm just showing you that this lives in theprotocol you'll be able to find all this, youknow, in the reporting instructions wehave the numerator and the denominator section. so when they have twodifferent ones and it's the same incision, you know,we're going to have that total time on both ofthem, you don't split those, and that's another reporting

instruction we already covered. let's do case 11. you have a 77 year oldfemale who is admitted for sudden onset ofsevere abdominal pain. an x-ray is performedin the emergency department it shows free air. she was admitted, theystarted here on pip tazo, taken to theoperating room for an xlap and they found a ruptured diverticulum

so she also obviously had acolo procedure was performed and they did a primaryclosure of the incision. now it's seven days laterand the patient developed new abdominal pain,abdominal distention, nausea, a ct scan showedpossible early abscess in the right peritonealcavity an interventional radiology drained theabscess and sent for culture and it came backpositive for staph aureus. and then the next day thepatient spikes a temp

and the blood is positivefor staph aureus. is this an ssi, and what kind? you got 10 more seconds. i'm looking at myslides and my time and i want to make sure ifinish up on time. good. the answer is organ space. they do have an organ space ssi and the specific site is iab. again, it's iab criterion 1.

remember that abscess was not anything in the deep pelvis it was just kind of the left over here. you don't have anythingthat showing it was sucked in to the deeppelvic area so that's where you would go to the iab definition, and itmet criterion 1. does this patient have asecondary bsi, yes or no? every one is voting niceand quick with this one.

this is an easy one. i think i'm going to get 100% on this. i'm feeling it. oh, ok. i'm still proud of you guys, but. the answer is they do. matching pathogen, right, in the abscess and theblood was matching. it met totally, totally met. all right, let's try another one, case 12.

you have a 77 year old female. she was admitted for suddenonset of the abdominal pain. the x-ray wasperformed-- this is very similar but we tweaked it. was performed in theor-- oh no, performed in the ed, free air,started on pip tazo, taken to the or for thexlap, same scenario, it's the same patient we're just switching it up,ruptured diverticulum.

then she comes back on the 9th. and she has a fever of38.8, new abdominal pain and distention, nausea,blood cultures obtained, a ct scan showed asmall fluid collection or abscess in the rightperitoneal cavity. the fluid collection wastoo small to drain. but the blood culture ispositive for staph aureus. does this patient meetcriteria for an ssi? and if they do, what criteria is it?

what do they meet interms of-- do they not meet, do they meetssi organ space iab with a secondary bsi, do they meet ssi organ space site iab, no secondary bsi, or isit ssi organ space git? oh, they don't meet, uh-oh. let's take it apart though, ok? because this is something that i have found is not uncommon.

and i'm going to take thisapart so you'll see why. this is iab criterion 3b. what did we only have,go back to your case. all we have is an imaging test and a couple symptoms, right? but they couldn't drain it, right? it wasn't able to be drained. and we have staph aureus in the blood, ok? so, that is not anallowable pathogen

now with the new criteria, see? it's not an allowable pathogen for 3b. so, all you reallyhave in this patient, ok, is an imaging testand some symptoms. that, an imaging test alone,and they didn't go in. and if you think of criterion1, they didn't drain it. you don't have pus. they didn't culture it. there's-- nothing happened.

you can't then find whatis in this patient. there may be other thingsthat develop later but at this point thispatient does not meet. think of that. when you have an imaging testalone, you're going to have to have, and i didn't do anything else. it was enough. you should've looked. that was right to look.

because that meetscriterion organ space, general organspace criterion c because you guys have this memorized. because there was an imagingtest suggestive, you know? but when you actuallylooked at it because they couldn'tgo and do anything in their small abscesses,it's not uncommon. i'm going to throwsome antibiotics on here and hopefully, this--

whatever is going on will clear it up. so, you have a 77year old female, was admitted for severeabdominal pain. an abdominal x-raywas performed, free air, sounding familiar? so we'll just skip that. now they're back in. this poor woman,they must have done like three of these in one day.

no. the patient developed fever, 38.8, new abdominalpain, distention and nausea, blood cultures were obtained. the blood cultures were positive e. coli. they took the patient--actually, it continued. and they took that patientto the or for an xlap and they've found anabdominal abscess, but no cultures were obtained. so, let's practice this.

they don't meet, sortof seem similar to the last case, but, or theyhave an ssi organ space with the specificsite of iab and a secondary bsi,ssi organ space, specific site iabwith no secondary bsi or an ssi organ space git? and you've got the iabdefinition in your handout because we tookit apart on two slides. so, if you're notsure, just flip back

a little bit onyour presentation. and you'll see where itook apart that iab definition if you needto look at that one. hint. all righty. ten seconds. and let's look at this. this is our new one. they had an abscess. when they took them back tothe or, they saw the abscess

and the surgeon did notculture the abscess but the pathogen they foundcompletely is part of b. so, this is an example of the new 2b that in the past you may have had to call that a primary bsi. now, this will be an iab with e.coli and you'll check secondarybsi equals yes. i do want to point out and we're going to put an faq about this.

and i think thati've heard from many users that they reallywant to be clear. and i'm going to-- thereis going to be an faq. it's written. we just don't have it inour new updates, that when they're talkingabout, this is really key that 2b means abscess orevidence of infection is seen. and we're not saying, they opened them up and they'd had a gi bleed and

there's some blood in there. we don't mean they openedthem up and they just had a recent leak in theirstool in the abdomen. it is that thatwhatever has happened has been in there long enough that they actually saw infection setup. i don't want youapplying high wound class for this,anything like that. they really have to have seen infection.

and just for some reason, they didn't choose to do a culture. but you've got that blood. let's go on to our nextcase, this is a 45 year old female undergoes anabdominal hysterectomy. comes back four dayslater with a temp of 38.4, abdominalpain and emesis. ultrasound shows afluid collection in the abdominal cavity.

serosanguineous fluidis obtained by needle aspiration andsent for culture and it's positive for e. faecium. so, that she meets organ space iab criterion 3a at this time. i'm kind of telling you that. see that serosanguineous,she had some symptoms. they did the ct-- the needle aspiration. so, that is an iab organ space 3a.

now, the patient, it's now 2/6. patient spikes a temp of 38.9. there's no abdominal pain,nausea or vomiting. but the patient has bloodand urine cultures collected. this poor patient musthave must have had complications if they'restill in the health. and the urine cultureis no growth but the blood cultures are positive for e.faecium. i'm kind of just lookingat the whole case.

all right, 10 seconds. good. and the answer is yes. does this patient have an ssi? and if yes, what ssicriteria did she meet? so, you guys said yes. what does she have? now, i'm making you do step 2. actually, i think i toldyou the answer to this one. we'll move right on.

i must have tweakedthis case and forgot. oh my gosh, and you guys didn't get 100%. i told you on that 3a in the case. come on. all right. anyway. i'm taking notesof what i want to fix. so, anyway, yes. she met criterion3a, the vomiting, abdominal pain andthe organism seen when they did the needleaspiration, that's 3a.

now does this patienthave a secondary bsi, that's the teachingpoint i was really getting to, attributableto the ssi? you guys are pretty fast on this one. i'm feeling good about it. about 10 seconds. so, no, she doesn'tbecause the secondary bsi attribution period foran ssi, you guys, is 3 days beforethe date of event

and 13 days afterthe date of event. so you guys who gotit right that she has an iab 3a, thatbsi occurs well after the secondary bsiattribution period. and i even told youthat at the time of that, she wasn'thaving nausea. she wasn't having more abdominal pain. she didn't have anything done. so, you know, what youwould have had to

look for, which youguys who got it right, did to see well did she-- is she still continuing to meet. and she doesn't and you'reoutside the secondary, so at that point you mightfind another source somewhere. but you just have toevaluate that blood once it's outsidethat secondary bsi. does she meet ongoing iab, which she did not, becausei had those--

showed what you had going onwhen that blood was drawn. so, you'll need to evaluate that like you would any other. is this primary maybea different source or is this going toend being, you know, an actual, you know, lcbi for you. the last day of that time period was 2/1. so, this is case 15, we're almost done. a 60 year old female wasadmitted with an acute abdomen.

and the patient wassent to the or and the finding was aruptured diverticulum with fecal contaminationof the abdominal cavity, they made it a wound classcontaminated, good. the colectomy is performedwith a colostomy formation. incision is looselyclosed with staples with packing in between toallow for drainage and the patient is placed on antibiotics. it's four days later,they're progressing

well and they sentthe patient home. and then the patient comesback about six days later with fever of38.5, abdominal pain, the ct scan issuspicious for small the md starts antibiotics andthe patient is discharged. no cultures are obtained. the discharge note statesthe patient returned with a possibleintraabdominal abscess. you guys are going to begetting so good at this

since i've thrown in somenewer ones before this. should this patient'schart be reviewed to see if they meet criteria fora possible organ space ssi? yeah. yes, i mean, this--there's enough red flags that you need tolike see what's going on. i've got a patient in the er and they've got some symptoms, ct. but when you take this apart,look what you have. you did could look at it because

they kind of havethat imaging test. it says, "we may have somesmall abscesses in there. so, you were right. let's move on and see if this meets a site specific criteria." so, now, do thinkthis patient meets criteria for a sitespecific infection? i'm going to close the poll because i'm really running late.

and i thing we mighthave to skip one case. there was like, no-- oh, 50-50. [ laughter ] nailed it [laughs]. oh man. all right. no. the reason, we're goingto now take this apart, ok? whatever those things they--maybe saw on a ct scan. they didn't ever cultureanything, they didn't culture an abscess, sothere's criterion 1.

the patient didn't go to the or where we could see anything, no. they didn't have a bloodculture associated with this and takethem to the or, no. they had some signs andsymptoms but they didn't have any organisms thatwere cultured, so, no. and they didn'tmeet this with an imaging and a bloodso they really-- its again that casei was alluding to

before you can havepeople come in but all they ever did washave, "they might have some small abscesses herelet me give them some antibiotics," but that won't be enough to really say youhave really meet our definition for anintraabdominal infection. so we have a male patientwho underwent a kpro. they went-- knee orthoplastyand they went to their md with a red warmto touch swollen knee,

the md aspirated thejoint and a specimen was sent for culture andthey were admitted, there was enough concernwith that physician. i don't know that looked likewhen they did the culture but that culture then cameback positive for mssa. it can take them a little bit to get them back to the hospital. he returned to theor where they did another i&d of thejoint was performed

and purulent materialwas found in the joint and more synovial fluid cultures and a deep tissue were obtained. the prosthesis wasremoved and an antibiotic spacer was placed and allcultures were positive for mssa and theyhave a blood culture positive for mssa the next day. which site specific definition should be applied for this case?

pji or periprostheticjoint infection or just the basic jointinfection definition? i'll give you five seconds. hint, this sort of changedlast year not this year. and that's correct, pji. remember last yearwas pji is the new organ spacedefinition to use for joint infections after hips and knees. you'll never findit on the drop-down

menu for anything else but a hip and knee surgical site infection. this is the definition and this patient met the pji criterion 1 with two positive periprosthetictissue specimens. i want to address do these have to be collectedat the same time, do they need to be collectedat different times. what we've seen happenespecially considering

a surgeon's scheduleor orthopedic schedule where they get their firstculture at an md's office and they get a single positiveculture and its mssa. they are concernedthey get-- they got to go through get thatperson readmitted to the hospital they needto get him on the schedule and now it's three days later they're back andthey're in the or and they get a secondperiprosthetic

culture and it matches. that is two matching. there was clearlyinfection going on at the time theydid the first one. they get him back tothe or that's why they are there and theyget the second one. they don't have to be obtained at the exact same or procedure. there were some folksthat were saying,

"well that was aninvasive manipulation." i'm like, "yeah and itwas culture positive, you know, in thedoctor's office." it wasn't like that--the whole thing had started theinfection process. it's on the same process. what is the date ofevent for this ssi that i just gaveyou the case for? remember--

five seconds this is an easy one. march 8. and that'scorrect that was the date that they got the firstpositive periprosthetic culture at thephysician's office. and that's the elementthat you're applying is because twomatching cultures. does this patient have absi secondary to the pji? you guys are fast. and the answer is yesbecause the positive

blood culture ismatching and occurred within the secondary bsitimeframe for an ssi. so that's why you'd have--you have selected yes for that fora secondary bsi. let's make this a different scenario, samepatient had a kpro. then is on 3/8, maybe wewent to this a little further down the roadthey went to their md, a red warm swollenknee the md aspirated

the joint and foundserous looking fluid. a single specimen was sentfor culture, no other labs were obtained andthe patient was started on antibiotics, senthome and then the culture came backpositive for staph epi. does this patient meet criteriafor an ssi yes or no? you guys are almost done. and the answer is noand i'll show you why. remember this is an h,this was a-- you had--

when you have a singlepositive culture which is e, see that singleperiprosthetic, you have to-- we have three thingsdone and i said the md didn't sendany other labs. you'd have to have, youknow, some sort of synovial fluid, whiteblood cell testing or you'd had to have some pmns and, you know, it's just they-- they just didn't do enough and

so-- and it's just a single-- you know, and maybe theycollected it poorly and it was contaminatedwith staph epi when they got it but it doesn'tmeet pji criteria. and you can't go back and try to say, "well i'llapply joint to it." you can't becauseafter knees they want to really makesure they nail it and these are good solidinfections that meet criteria.

it's just not going to meet criteria. all right, you need a belly rub anybody? yup, yup, so, anyway,this is short we're just going to reallyquickly go over. that's the end of likethe cases of how to fill out completing yournumerator event form and i'm going to kind of whiz through this andi'll be able to stay after, there's a break afterthis for any questions.

you already saw this isyour form and anytime you see an asteriskit's a required field like with all the other applications. you are going-- these are the fields that are required fields. now, that medicarenumber is only required for eventsnot for denominators. then we go on and talk aboutlike selecting yes, no. that's a required fieldmake sure you tell

us if it's an outpatientprocedure or not. and if you are notfollowing mdro's infection surveillanceas an option at your facilitythis will always be no and it's notjust to say, "yeah, i got something with mrsathat should be an mdro." it's no. it's you'd befollowing that protocol you tell us here thatyou're following that. enter the date thepatient was admitted,

when the procedurewas performed. you can get anerror message if a person is readmitted and you put on the date admittedthe facilities the date they're readmitted because then it can confusesthe application like, "well, their surgery was back there how could they be readmitted?" so when they put theadmission date for

when they did theoperative procedure that you're going to link this ssi to. but it's a smartapplication so you'll get an error message ifyou try to do this and you're like,"oops forgot, let me go get the otheradmission date." this location andthe icd-10 and cpt fields are stilloptional fields. here is where you see the patos

field right under your events. so this is someonewho is-- this is the reminder of the sitespecific criteria, the elements thatyou'll use to identify you just go to thatpart of the form and fill everything in that meets. if the field is grayedout it means it's not an option for that particularinfection you're kind of trying to enter it'll be-- it

won't be a livebox, so to speak. we didn't change any ofour ssi event details these are requiredfields you're just going to tell us how you found, what method of surveillance you were using to find this particular ssi. so if the ssi was[inaudible] at like p is post-dischargesurveillance including that would be an ed visitand they just go home.

if they are readmittedfrom-- if they send them to the ed and then sendto your facility, that would be readmitted to your facility not post-discharge because they actually thenended up having a readmission. again, like the otherforms or question about was is this ssi contributedto death yes or no? back in the olden days that was an unknown and that went away-- i meanwe're talking olden days.

but what we did now iswe're much clearer and again this is in yourtable of instructions if you got confused you can look up how to fill in this field. it's if you-- the patientdied check yes if such evidence is availablelike it's documented that this ssi-- that they died from complications of an ssi or an autopsy note, otherwise check no.

we're not having youmake the call and go say, "yeah, this ssikilled the person." you need to havedocumentation that, yes that someone pointedto this complication of their ssi as apotential cause of death. we're all like, "i'm goingto take care of my license." linking procedures is really important. so every time you've gotall your denominator data in there and nowyou filled out on ssi

and now we want to linkthese two together. and the biggest issuethat happens and this is where you're loadingyour risk factors that are underlyingeverything you took all that time to fill in, in your procedure isnow underpinning the ssi that was found thatyou're putting in. so, you can't link aprocedure if you-- the denominator isn't alreadyin your application,

they won't linkbecause you can't-- it won't be able to find it. so you enter thedenominator first then you have to enter thessi and link them. and here is what--if you-- and this is important and it's whatcauses error messages where you'll say, "we can'tfind that procedure." don't-- this is now your ssi event. don't fill a bunch of this in yourself.

just say you're doingan ssi, just put in the date of event andthen go link event. see that button, you'll get link event. when you do that, it'sletting the application go find it and fill inall the information. if you fill in anythingdifferent on this yourself manually,then what was entered in the denominator,it's going to say, "nothing to link,it's not right."

so, let it do the work,i'll show you that here. so i just said link that event. and i went in and i foundthis patient and they have that colo performedand it's the right one, it's the one i'm workingup that was done on 1/5 and i just hit that linkbutton and it's going to fill in that information for me. see how now it found theprocedure date in that? because what if you thought the

procedure was done on 1/6? if you'd put that in and said, "linked." you'd get an error message. and that was somethingthat i don't think because i didn't do alot of data entry. when i was at a largerfacility, i didn't really get how picky thiscan be but it's picky because it wants to beright -- and really make sure it'sgot the right data.

and now, they're alllinked together, the information and thenyou'll hit save. i am-- this is you'vebeen hearing it so much because we'vedone such a good job with all our analysisbut again, you're going to-- when you hitthis landing page, you can see, you havemissing procedure events and if you havethose it's probably that you forgot that youhave colo in your plan

but you did not have anyssis attributable to that. so it just wantsto make sure you didn't forget toenter some ssis. so you want to say, "reportno events," and then save. so, we do have just a coupleminutes for questions. i know this has been a bit long, but. i think that's photoshopped. that is not my dog. my dog is a lot fatter that than.

[ applause ] let's say we gotabout three minutes but i will stay downhere and denise, who is my other partner in crime. many of you when yousend questions to the ssi questions it wouldbe either denise or i answering thoseso in case there's, you know, questions she's going to during the break be down with me too.

and you do have a 15minute break that will-- you'll be back-- needto be back here at 2. yes. >> i actually have two questions. one is in the definitionfor deep incisional ssi and some other definitionswhere it's two parts. if that is the criteriayou're using to meet the definition and youhave a different date for part a andpart b, which date

do you use as the date of event? >> the first one. so if you're talking-- >> -- about like criteriondeep incisional-- criterion-- >> b with deep incisionsspontaneously dehiscences and thenlocalized pain and-- >> yes, yeah. and again and you don'thave to have the infection window periodbut i do want to say

and i don't see people abusing this. we won't-- don'twant to fight the temperature the dayafter they had surgery and then they're coming back 21 days later with the dehiscence. you know, we don't makeyou have an infection window period butyou're not going to do anything crazyin terms of having them clustered in areally far out in time.

yes, it would bethe first element that you're usingin the definition-- >> ok.>> -- it was part of the definition. >> and if we havean infection that we're fairly certainis due to an ssi but it is not an nhsn procedure,do you still want us to call it something elselike let's say, it's an-- >> oh, good question, yeah. so because we tookaway the oth other

group is what she'sreferring to. and-- but the patient comesback from a procedure. it's not an nhsn one we haveto think of it that way. they have-- they're in the hospital, they have one of theseother procedures done and they developan infection. i don't want to think of it as an ssi i have an infection. what you're doing withthose procedures is

applying your hai criteriajust like you would for a trach site infection or localize g-tubesite infection. it may meet hai butyou then have to apply hai criteriaso it would need to have an infection window period. you wouldn't have a long 30 day surveillance period for it, so. if you want to follow--if there's a particular

one of those thingsyou feel like, "oh, we are having a problem withthat i want to follow it." you'd follow it under,as an hai not an ssi. >> thank you. >> sure. >> hi. quick question about patos. >> yes. >> so, we understandit's not same as present on admission but myquestion is are there plans

to remove those ssis that are result-- >> -- of patos fromeither the cms reporting of the sir or from anyof the other-- >> yes. that is whatwe actively, actively looking at and maggieis going to be addressing thatwhen we talk about our re-baseliningthat's going on. we've taken all thatpatos information you've been sending us andwe're analyzing it

and it is looking very likelyfrom what i've heard based on that it is mostlikely maybe excluded from-- not from youtelling us about it. they're ssis but it's still to be seen. we're getting veryclose to giving you an answer on that and assoon as we have an answer on that we'll be sharing that information. and kathy, am i giving honesty to that?

oh, i got thumbs up from maggie. it's being analyzedas we speak, i go to the break room and ilisten for anything and i hear them say patos and i grab the person, yeah, but-- >> ok. so it sounds likein risk adjustment, as-- well it will be soour risk adjustment-- >> -- and potentially toremove those from the sir-- >> potentially, yes.you got it.

>> ok, great. >> and maggie is going toaddress it again, but. i'm not-- and you guys,i'm going to let you break because it ispast your break time and i know there'slong lines for things and denise and iwill be down front if there's anything and thank you so much.

Drop 5lb of belly fat in 3 day [1-2lbs PER DAY!]

What if I told you there is one simple tweak you can implement today that will force your body to get rid of stubborn, unwanted belly fat everyday for the rest of your life... Would you be interested in that? Good news is...



You can literally lose 1-2lbs of belly fat every single day with this!



This is a new diet “trick” from a european doctor that can help you lose 1-2 lbs of belly fat per day! So...

Check It Out Here And Lose 5lbs