infection control & hospital epidemiology october 2017, vol. 38, no. 10 original article


Structure, Process, and Outcome Quality of Surgical Site Infection Surveillance in Switzerland


Stefan P. Kuster, MD, MSc;1,2,a Marie-Christine Eisenring, CNS, ICP;1,3,a Hugo Sax, MD;1,2 Nicolas Troillet, MD, MSc;1,3,4 Swissnosob


objective. To assess the structure and quality of surveillance activities and to validate outcome detection in the Swiss national surgical site infection (SSI) surveillance program.


design. Countrywide survey of SSI surveillance quality. setting. 147 hospitals or hospital units with surgical activities in Switzerland. methods.


Site visits were conductedwith on-site structured interviews and reviewof a random sample of 15 patient records per hospital: 10 from


the entire data set and 5 from a subset of patients with originally reported infection. Process and structure were rated in 9 domains with a weighted overall validation score, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the identification of SSI.


results. Of 50 possible points, the median validation score was 35.5 (range, 16.25–48.5). Public hospitals (P<.001), hospitals in the Italian- speaking region of Switzerland (P=.021), and hospitals with longer participation in the surveillance (P=.018) had higher scores than others. Domains that contributed most to lower scores were quality of chart review and quality of data extraction. Of 49 infections, 15 (30.6%) had been overlooked in a random sample of 1,110 patient records, accounting for a sensitivity of 69.4% (95% confidence interval [CI], 54.6%–81.7%), a specificity of 99.9% (95% CI, 99.5%–100%), a positive predictive value of 97.1% (95% CI, 85.1%–99.9%), and a negative predictive value of 98.6% (95% CI, 97.7%–99.2%).


conclusions. Irrespective of a well-defined surveillance methodology, there is a wide variation of SSI surveillance quality. The quality of chart review and the accuracy of data collection are the main areas for improvement.


Infect Control Hosp Epidemiol 2017;38:1172–1181


Surgical site infections (SSIs) are the most common hospital-acquired infections; they are associated with increased morbidity and mortality, prolonged length of hospital stay, and increased cost.1–6 Infection surveillance with feedback has been shown to reduce SSI rates.7 Nationwide SSI surveillance has been performed in Switzerland since 2011.8 In line with a broader international trend, SSI rates of each participating hospital have beenmade publicly available since 2014, reinforcing the need for valid data collection. Surveillance methods should be standardized to ensure the quality and reliability of surveillance data.9 The accuracy of the


data depends on the experience, qualifications, training, and awareness of the surveillance staff.10,11 Validation is the only independent means to determine the accuracy of surveillance data; thus, validation is essential in determining the reliability of a SSI surveillance network in which data are aggregated from multiple data collectors and are used for comparisons among hospitals.12,13 Validationmeasures are designed to detect potential sources of


bias. With regard to validation of SSI surveillance, particularly selection bias (methods of patient inclusion), information and detection bias (completion of required medical information), and


Affiliations: 1. Swissnoso - National Center for Infection Control, Bern, Switzerland; 2. Division of Infectious Diseases and Hospital Epidemiology,


University and University Hospital of Zurich, Zurich, Switzerland; 3. Service of Infectious Diseases, Central Institute, Valais Hospital, Sion, Switzerland; 4. Services of Infectious Diseases and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.


PREVIOUS PRESENTATION: These data were presented in part at the Fourth International Conference on Prevention & Infection Control (ICPIC) on June 23, 2017, in Geneva, Switzerland aAuthors of equal contribution. bMembers of Swissnoso are (in alphabetical order): Carlo Balmelli, MD, Lugano; Marie-Christine Eisenring, RN, ICP, CNS, Sion; Stephan Harbarth, MD, MS, Geneva; Stefan P. Kuster, MD, MSc, Zurich; Jonas Marschall, MD, MSc, Bern; Virginie Masserey Spicher, MD, Bern; Didier Pittet, MD, MS, Geneva; Christian Ruef, MD, Zurich; Hugo Sax, MD, Zurich; Matthias Schlegel, MD, St. Gallen; Alexander Schweiger, MD, Basel; Nicolas Troillet, MD, MSc, Sion; Andreas F. Widmer, MD, MSc, Basel; Giorgio Zanetti, MD, MSc, Lausanne.


© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3810-0006. DOI: 10.1017/ice.2017.169 Received March 14, 2017; accepted July 11, 2017; electronically published August 22, 2017


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