Patient-Directed Active Surgical Incisions Surveillance May Lead to Further Surgical Site Infection Reduction

Surgical site infections (SSIs) have been a concern of those caring for patients who undergo operations since operations have been performed. Surgical site infection is a serious potential outcome and a specific complication tied directly to the time of the operation, the skill of the surgeon, the precautions and preventive measures taken, and the underlying risk factors of the patient. There are multiple references to the fact that an SSI increases morbidity, mortality, length of hospital stay, and cost of care [1–3]. For this reason, accurate detection and recording of SSIs has been considered an important element of the medical system for many years. In addition, there is a large body of data supporting the idea that accurate surveillance of SSIs and notification of the care team can improve efficiency of care and reduce the overall burden of surgical infections.

In the mid-1970s the U.S. Centers for Disease Control and Prevention (CDC) began designing and initiating a project called the Study on the Efficacy of Infection Control (SENIC) as part of the National Nosocomial Infection Surveillance (NNIS) project [4,5], a precursor to the CDC's National Healthcare Safety Network (NHSN) [6]. The goal of SENIC was to explore the uses of a national surveillance program and to determine whether it had the capability to influence nosocomial infection rates. Early research from SENIC data demonstrated that effective surveillance combined with feedback to clinicians and healthcare administrators was associated with reduced rates of hospital-acquired infections (HAI) [7,8]. This was particularly demonstrated for SSIs (9), and this effect has been demonstrated repeatedly since that time [10–14].

In the current era, surveillance of SSIs and other HAIs is an assumed responsibility of modern hospitals and increasingly so of outpatient surgical centers. However, the degree to which all surgical procedures are monitored, and the methods used for the surveillance are highly variable across medical institutions. Currently Medicare and 34 states require a degree of surveillance for selected surgical procedures (hysterectomy and colectomy), but not for all procedures whereas several states require additional SSI reporting, most commonly hip and knee prostheses and cardiac bypass surgeries [15,16]. Medicare expects hospitals to use the NHSN system that is operated by the CDC, but the intensity with which this surveillance is done varies from institution to institution and although NHSN policies specify surveillance of patients after hospital discharge (17), the details of how this should be done are not specified. There are convincing data that, in the modern era, more than half of all SSIs are not diagnosed until after hospital discharge [18–25]. How surveillance is done and what system is used can markedly affect the number of SSIs detected [26–29].

Another system of surveillance is illustrated by the National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons (ACS), which has trained surveyors to establish guaranteed follow-up of selected surgical patients for 30 days after the operation [30]. However, NSQIP is a program that is selected and paid for by participating hospitals in the country and currently involves only 589 hospitals in the United States in addition to 123 hospitals in 13 other countries [31]. Some comparative studies have demonstrated that at the same hospital in which both NHSN and NSQIP are used for SSI surveillance, NSQIP always finds a larger number of SSIs [26,27,29]. A number of hospitals have reported reduction in SSIs after joining the NSQIP program [32,33].

Another area that has received attention in recent years is the value of using patient-generated health data (PGHD) to assist in our care of patients. Without doubt, the patient is the closest to what is happening after any medical encounter and combining the patient's report of experiences with the medical professional's knowledge should enable us to provide better and more timely care and interventions when indicated. A specific use of PGHD most relevant to surgical patients that has been growing in recent years is facilitated by systems that encourage patients to take pictures of their surgical incisions and send them to their surgical team for evaluation. Although there is not complete agreement and there is room for further improvement, several studies report reasonable agreement between in-person examinations and evaluation of incision images [34–37].

Early reports show that this model of patient involvement can in some cases avoid unnecessary unscheduled urgent care or emergency department visits and in other cases detect SSIs at an earlier time and promote earlier, effective treatment [38]. In today's surgical practice, patients leave the hospital at shorter intervals after operation than as recently as only 10 years ago, and in many cases travel home to locations at substantial distance from where their operation was performed. The use of patient images of surgical incisions guided by standards established for this purpose and accompanied by answers to standardized questions regarding recovery could improve timeliness and accuracy of care and could also improve surveillance.

There is a tendency for surgeons and other healthcare practitioners to examine surgical incisions and worry about infection in the early days after operation. However, multiple studies report that the majority of SSIs are not diagnosed until a week or later [39–44], which is often after discharge. There is evidence that in healing incisions, erythema decreases between days one and three after operation [45], and early concerns and treatment for mild erythema is not likely to be helpful [39]. In addition, a degree of temperature elevation is common in the early days after operation and is also usually not associated with SSI [46–50]. Many patients are now being treated with negative pressure dressings that may stay on past discharge. Thus, for many patients, incision images and symptom information obtained after discharge and communicated to the surgical team may be more valuable. Although patients by themselves may tend to misdiagnose potential SSIs [51,52], provision of validated PGHD including images to the surgical team could aid provision of the most appropriate care.

Specifically, patients could be encouraged to provide pictures and subjective information at intervals up to 30 days even when travel back to the surgeon's office is impractical and/or expensive. This could achieve much more complete surveillance data on SSI rates that could be fed back to surgeons and assist in reducing SSI rates. Another issue in modern medicine with patients traveling distances for surgical care and with primary care and other specialty care providers separated from one another and the surgical team is the frequent lack of full communication to all members of the care team and the subsequent potential reduction in quality of care for the patient. If a well-coordinated system existed for sending the pictures and patient information to everyone on the patient's care team this could improve coordination of care as well as provide more accurate and complete SSI data, both for the patient and for its benefit to the care team.

I have not seen published studies to this affect but have discussed it with several colleagues who also agree that collaborative data sharing between surgeons and infection preventionists can enhance SSI surveillance overall and overcome gaps in surveillance strategies (C.L. Passaretti and C.E. Reinke, personal communication). At recent presentations about mobile health (mHealth) and PGHD at meetings of the Surgical Clinical Outcomes Assessment Program (SCOAP) in the state of Washington and Safe Table meetings of the Washington State Hospital Association and in a discussion panel regarding this topic at the 2018 NSQIP ACS National Surgical Quality Improvement Conference in Orlando, Florida on July 24, 2018, there was considerable enthusiasm for this from audience participants.

One area that still needs attention is a way to transmit the patient-generated images to the healthcare team in a manner that protects their private health information. There are two primary sets of regulations that govern, and encourage, this new role for patients in SSI surveillance. Because surgeons and health care organizations are covered entities under HIPAA, protected health information recorded, received, or maintained by covered entities must be in accordance with the HIPAA Security Rule [53]. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) includes incentive measures under the Promoting Interoperability category, two of which specifically encourage patient-directed activities. These are “Patient Generated Health Data” (including patient data from nonclinical settings) and “Provide Patient Access” (provide data to patients electronically). Further development in this area is needed.

In summary, accurate and complete surveillance of SSI with feedback to the clinical team has been demonstrated to improve outcomes and reduce infections. The addition of PGHD with images provided in a reliable and consistent fashion to the surgical and other medical care teams has the potential to improve the care of surgical patients. Convincing patients of the value of this approach and finding a way to integrate these data into the clinical workflow at the right time for providers to access the data would be a significant advance in patient care.