QAPI 126 - Enhancing SSI Reviews Through Secure Electronic Data Capture

Background: Review of individual Surgical Site Infections (SSI) is typically a siloed process at our facility: surgeons, Infection Prevention (IP), and perioperative departments review the event separately, using mixed methods. Chart review is required to assess adherence to best practice, due to difficulties electronically mining data from health records. Our facility successfully initiated device-related infection case reviews, hand hygiene compliance, and device monitoring, with a secure electronic data collection (SEDC) tool, in 2022. Building on these successful applications, we sought to determine if utilizing SEDC for SSI reviews, could standardize work, engage perioperative partners, and enable data aggregation/analysis.

Methods: A SEDC SSI review database was created by IP and launched in October, 2023. IP collaborated with perioperative partners to develop evidence-based best practice questionnaires. SSI reviews from multiple phases of care and disciplines were combined into one summary that could be reviewed and aggregated. SSI confirmation by IP initiated the process, which utilized a downloaded surveillance system line list uploaded into SEDC database, eliminating need for IP data entry. Individual questionnaires were automatically sent to perioperative leaders for completion, following IP form submission. Surgeon reviews were optional, as some had established peer review processes.

Results: Twenty-five SSI case reviews have been initiated, with an 88% completion rate, excluding surgeon reviews, which had 32% completion. IP has begun to standardize reviews within each service line, utilizing line lists with hyperlinks to qualitative and quantitative summaries. Process feedback from perioperative nursing stakeholder was positive. Initial analysis of aggregate data has identified prevention opportunities.

Conclusions: SEDC has enabled our hospital to grow our SSI reviewer group, diversifying the perspective and uncovering opportunities that IP would not otherwise have known about. We have also been able to standardize how infections are evaluated and communicated internally, increasing awareness and data accessibility to all stakeholders.