Infection Control & Hospital Epidemiology
appropriately target surveillance and prevention efforts.8 Therefore, we aimed to describe the epidemiology of SSI in children after ambulatory surgery.
Methods Study design and setting
We conducted a prospective, observational study to describe the epidemiology of SSIs after pediatric ambulatory surgery across the Children’s Hospital of Philadelphia (CHOP) Care Network. At the time of the study, the network, located in southeastern Pennsylvania and southern New Jersey, included 3 freestanding ASFs, 1 hospital-based surgical facility, 29 primary care practices, 8 specialty care centers, a 521-bed acute-care hospital, and an emergency department. All sites used a common electronic health record (EHR, Epic Systems, Verona, WI) except for surgical procedure data prior to May 2013, which were collected and stored in OR Manager (Picis Clinical Solutions, Wakefield, MA). Decisions regarding the location of ambulatory surgical encoun- ters are dictated largely by patient and clinician preferences, which include nonclinical factors such as parental preference and ease of scheduling. The CHOP Institutional Review Board reviewed and approved this study.
Study cohort
The EHR data were extracted biweekly for children <18 years of age who had an ambulatory surgical procedure (ie, with admission, procedure, and discharge on the same calendar day) performed at any of the 4 surgical centers (ie, 3 ASFs and 1 hospital-based facility). A surgical procedure was defined using 2010 National Healthcare Safety Network (NHSN) criteria, which required that the procedure was performed in an operating room and that incision and complete closure of the wound occurred during the same operating room visit.9 Eligible wound class 1 and 2 procedures were identified from the procedure name (free-text field) recorded by the surgeon in the EHR after the procedure was performed. Multiple surgical procedures performed during a single operating room visit were included as long as all procedures met NHSN surgery defini- tions or the additional procedures that did not meet NHSN surgery definitions did not involve penetration of sterile tissue by an instrument or medical device (eg, ear tubes, cystoscopy, biopsy) or an open wound (eg, debridement, closure). Eligible surgical encounters were identified at the 3 ASFs between June 2012 and December 2015 and at the hospital-based facility between August 2012 and December 2015. Children could be enrolled more than once if they hadmultiple surgical encounters (ie, OR visits) thatmet eligibility criteria over the study period.
Data collection
Parents or guardians were contacted by phone between 30 and 45 days after their child’s surgical encounter. At the time of phone contact, non–English-speaking parents or guardians were exclu- ded. The guardian provided verbal informed consent for both the telephone interview and the review of data from the EHR. If consent was obtained, a structured telephone interview was completed. The interview included questions about healing of the surgical site, including the occurrence and details of any health- care encounters during the initial 30 days after the surgery. Additionally, occurrence and details of any healthcare encounters
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in the CHOP network were abstracted electronically from the EHR for up to 60 days after surgery for each child. Manual case reviews of the EHR were conducted by 1 of 2
certified infection preventionists, each of whom had more than 20 years of experience working in infection prevention and control. A manual case review was completed if the interview indicated a potential postsurgical complication or if electronically abstracted EHR data indicated that an antibiotic was prescribed or that the child had an emergency department visit or hospitalization during the surveillance window. For manual case reviews of the EHR, the infection preventionist documented diagnoses (ICD-9 diagnosis codes as well as diagnoses from clinical notes), wound descriptions, culture orders, antibiotic treatment, recommenda- tions for over-the-counter medications, and related follow-up procedures (eg, incision and drainage procedures). The manual case review covered the 60 days after the surgical encounter.
Procedure category
Eligible procedure names (free-text field) were grouped into 50 procedure categories by 2 pediatric infectious diseases specialists with experience in hospital epidemiology/infection prevention and control (S.E.C. and J.S.G). If multiple procedures in the same procedure category were performed in a single surgical encounter (ie, OR visit), the surgical encounter was counted only once for that category. However, if multiple procedures of different cate- gories were performed in a single surgical encounter, the encounter was counted for each category. For example, a single surgical encounter with adjacent tissue transfer or arrangement, chordee correction with circumcision, and repair of concealed penis would be counted in 2 different procedure categories: skin and/or tissue graft (first procedure) and penile reconstruction (second and third procedures).
Outcomes
We used 2 different definitions to identify infectious events associated with surgery. First, we identified SSIs assessed in the 30 days after the surgical procedure by applying 2010 NHSN definitions including superficial, deep, and organ-space infec- tions.10 Second, we developed and applied a broader definition to describe evidence of possible infection associated with surgery. We developed this “expanded” definition for 2 reasons: First, NHSN SSI criteria require clear documentation of each qualifying element in the EHR; thus, an infection reported by the parent but for which there was no documentation in the EHR (eg, if a patient had been evaluated in a nonnetwork emergency department) would not meet this NHSN definition. Second, NHSN SSI criteria exclude certain infectious events (eg, cellulitis) that may be related to surgery if it occurs at the wound site. Therefore, we aimed to develop an expanded definition that would capture all possible events with high sensitivity. The expanded definition included independent assessments of data obtained from the interview and the EHR review (Fig. 1) and categorized each surgical encounter by the strength of evidence (some or strong) for possible infection reported in the interview or documented in the EHR. The nature of the evidence required varied depending on the source (inter- view vs EHR). The expanded definition was applied to the interview data for the 30 days after surgery and the EHR data for the 60 days after surgery. The expanded definition was con- structed to ensure that any SSI meeting NHSN criteria would also meet the expanded definition criteria for strong evidence of
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