Leveraging Electronic Medical Records for Improved Performance in Surgical Site Infections

Authors:
Drishti Lall, Yeshwanth Vedire, Abigail Ruby, Eman Chami, Anita Shallal, Arielle Hodari Gupta

Body of Abstract:
Background

Surgical site infection (SSI) rates are reported by institutions and monitored by organizations such as the CDC National Healthcare Safety Network (NHSN) and Centers for Medicare and Medicaid Services (CMS). Accurate reporting of SSI requires distinguishing between infections present at time of surgery (PATOS) and those occurring in the post-operative period. Internal data for reported SSI rates for colon surgeries (COLO) at our institution revealed inaccurate reporting of SSI due to misclassification and absence of documentation for infections present at the time of surgery (PATOS). To combat these missed opportunities for accurate documentation, we leveraged the electronic medical record (EMR) in operative notes. This study evaluates rates of infection PATOS in COLO and the impact of the intervention on reported rates of SSI for COLO.

Methods

This was an IRB exempt descriptive study at our single tertiary care and level 1 trauma center in southeast Michigan. Beginning in 2022, a standardized EPIC SmartPhrase became available system wide which could be included in operative reports. This SmartPhrase included a drop down menu of descriptors that met criteria for appropriate classification of infection or contamination PATOS. Chart review was used to quantify infection PATOS and reported SSIs between 2020-2024 for COLO cases. The primary endpoint was the number of COLO PATOS cases per year. Descriptive statistics was utilized.

Results

Following implementation of the PATOS initiative in 2022, reportable SSIs for COLO decreased from 18 cases in 2022 to 16 in 2023, and further to 11 in 2024 [Figure]. During this same period, documented PATOS cases rose from 9 in 2022 to 16 in 2024. Examples of non-standardized terminology used to describe infections PATOS in operative notes that do not utilizethe standardized dot phrase included “air fluid collection in pouch of Douglas,” and “dilated, malperfused colon.”

Conclusion

Implementation of a standardized PATOS SmartPhrase in colon surgery operative notes resulted in an increase in accurate documentation of infections PATOS, with a corresponding decrease in reportable SSIs for COLO at our institution. Continued implementation of the PATOS initiative to promote consistent use of the standardized SmartPhrase in all operative documentation could continue to improve accurate documentation of infections PATOS and potentially have a significant effect on reportable SSI rates.