Standards reporting guide - Appropriate use of surgical antibiotic prophylaxis [SSA]
To provide the HQCC with an indication of the degree to which your hospital is complying with this standard, we have developed reporting requirements. These are made up of a set of measures with related data items.
A brief description of the measures, including their rationale and interpretation notes is presented below. Each measure is derived from one or more data items. The data items are the questions or specific pieces of information that are required to be reported to the HQCC. The data items are described below the Measures section.
All data items relate to the reporting period, unless otherwise specified.
Measures
Proportion of surgical patients who acquired a surgical site infection (SSA_M1)
| Rationale: |
Measure of outcome. |
| Interpretation: |
Low proportion expected. Surgical site infection may be attributed to causal factors other than lack of appropriate antibiotic prophylaxis (e.g. damage to tissues, excessive soiling, poor surgical technique). Excludes infections detected after discharge. May be based on full population or sample audit. |
| Data items: |
SSA_D3, SSA_D2 |
Proportion of principal surgical procedures where the patient received antibiotic prophylaxis in line with the principles of the Therapeutic Guidelines Antibiotic Expert Group. Prophylaxis surgical. Antibiotics Guidelines. 14th ed. (SSA_M2)
| Rationale: |
Measure of process and demonstrates level of compliance with standard. |
| Interpretation: |
High proportion expected. May be based on full population or sample audit. |
| Data items: |
SSA_D6, SSA_D5 |
Can you demonstrate that your hospital follows a process for the appropriate use of surgical antibiotic prophylaxis that includes all the criteria of the HQCC Appropriate use of surgical antibiotic prophylaxis standard? (SSA_M3)
| Rationale: |
Demonstrates existence and alignment of process. |
| Interpretation: |
Yes expected |
| Data items: |
SSA_D7 |
Can you demonstrate that your hospital has analysed data related to the appropriate use of surgical antibiotic prophylaxis to identify risks to patient safety and opportunities for quality improvement? (SSA_M4)
| Rationale: |
Demonstrates analysis of relevant data to identify risks to patient safety and opportunities for quality improvement. |
| Interpretation: |
Yes expected |
| Data items: |
SSA_D8 |
Can you demonstrate that your hospital has implemented quality improvement activities related to the appropriate use of surgical antibiotic prophylaxis? (SSA_M5)
| Rationale: |
Demonstrates quality improvement. |
| Interpretation: |
Yes expected |
| Data items: |
SSA_D9 |
Data items
The data items are the questions or specific pieces of information that are required to be reported to the HQCC. These are listed below with a brief technical description. The HQCC will calculate the measures (listed above) based on the data items provided. Underlined terms are defined in the
glossary.
Ideally, the HQCC prefer the data reported to be based on the full population (i.e. all patients or all procedures). We understand that without integrated electronic systems to routinely capture key information as a by-product of work processes this may be impractical for many providers and may not reflect the most efficient use of your hospital’s resources.
If you can not report data for the full population for data items SSA_D2, SSA_D3, SSA_D5 and SSA_D6, the HQCC will accept data based on a sample (however, the full population is required for data items SSA_D1 and SSA_D4). Further information on sample audits is provided for each relevant data item below and in the sample audit guidelines (see Sample size for audits and Sampling methodology for audits above).
Total number of surgical patients (SSA_D1)
Full population size of all admitted patients who underwent a surgical procedure.
Include admitted adult patients who underwent a surgical procedure. Include obstetric patients who underwent a surgical procedure. Include day procedure patients who are admitted.
Exclude non-admitted patients.
The full population is required for this data item - a sample audit is not acceptable.
If a sample audit is used for other data items in this standard, this number can be used to determine the effectiveness of the sample size.
Type: Number
Number of surgical patients in the audit (SSA_D2)
If you can report SSA_D3 based on the full population, do so and report the population size (SSA_D1) as the size of this audit (SSA_D2).
If you are unable to report on the full population, audit a sample of admitted patients who underwent a surgical procedure (see description for SSA_D1). See sample audit guidelines for advice on recommended sample size and methodology (see Sample size for audits and Sampling methodology for audits above).
Count the number of surgical patients in the audit.
Type: Number
Number of surgical patients who acquired a surgical site infection (SSA_D3)
Based on the audit of surgical patients, see SSA_D2.
Count the number of patients in the audit who acquired a surgical site infection.
Include only infections that are detected before discharge.
Type: Number
Total number of principal surgical procedures (SSA_D4)
This is the same number reported as CCC_D4.
Full population size of principal surgical procedures.
The definition of principal surgical procedures includes procedures that are surgical in nature, carry a procedural risk and are performed for diagnosis/investigation/treatment of the principal diagnosis. Procedures which are non-surgical in nature, such as anaesthetic or other additional procedures, should not be counted.
In counting the total number of principal surgical procedures, include principal surgical procedures conducted on:
- admitted adult patients who underwent a surgical procedure
- obstetric patients who underwent a surgical procedure
- day procedure patients who are admitted.
Exclude principal surgical procedures conducted on non-admitted patients.
Please note that the number of principal surgical procedures in the reporting period may be different from number of surgical patients in the reporting period if a patient had more than one surgical procedure in the reporting period.
The full population is required for this data item - a sample audit is not acceptable.
If a sample audit is used for other data items in this standard, this number can be used to determine the effectiveness of the sample size.
Type: Number
Number of principal surgical procedures in the audit (SSA_D5)
If you can report SSA_D6 based on the full population, do so and report the total number of principal surgical procedures as the size of this audit (SSA_D5).
If you are unable to report on the full population, audit a sample of principal surgical procedures (see description for SSA_D4). See sample audit guidelines for advice on recommended sample size and methodology (see Sample size for audits and Sampling methodology for audits above).
Count the number of principal surgical procedures in the audit of surgical patients.
The definition of principal surgical procedures includes procedures that are surgical in nature, carry a procedural risk and are performed for diagnosis/investigation/treatment of the principal diagnosis. Procedures which are non-surgical in nature such as anaesthetic or other additional procedures, should not be counted.
Please note that the number of principal surgical procedures in the reporting period may be different from number of surgical patients in the reporting period if a patient had more than one surgical procedure in the reporting period.
A sample audit is acceptable for this data item.
The same sample could be used for CCC_D5.
Type: Number
Number of principal surgical procedures where the patient received antibiotic prophylaxis in accordance with surgical antibiotic prophylaxis guidelines (SSA_D6)
Based on the audit of surgical patients, see SSA_D2.
Count the number of principal surgical procedures in the audit sample of surgical patients where the patient received antibiotic prophylaxis in accordance with surgical antibiotic prophylaxis guidelines. Procedures which are non-surgical in nature, such as anaesthetic or other additional procedures, should not be counted.
The surgical antibiotic prophylaxis guidelines referred to are the Therapeutic Guidelines Antibiotic Expert Group. Prophylaxis: Surgical. Antibiotics guidelines 14th Edition. Melbourne: Therapeutic Guidelines Limited 2010.
Type: Number
Can you demonstrate that your hospital follows a process for the appropriate use of surgical antibiotic prophylaxis that includes all the criteria of the HQCC Appropriate use of surgical antibiotic prophylaxis standard? (SSA_D7)
Answer Yes or No only. The hospital’s process must include all criteria of the HQCC standard. The HQCC may request further information about alignment with the standard.
Type: Yes/no
Can you demonstrate that your hospital has analysed data related to the appropriate use of surgical antibiotic prophylaxis to identify risks to patient safety and opportunities for quality improvement? (SSA_D8)
Answer Yes or No. The HQCC may request further information about the analysis.
The analysis may take the form of looking at performance trends across time, reviewing performance against benchmarks or peers, looking for subgroups within your hospital (such as wards or clinicians) with better or worse performance, looking for subgroups of patients with better or worse outcomes.
The analysis could look at outcome data, such as infection rates, or process data, such as prescription of appropriate antibiotic prophylaxis, reviewing clinical incidents or complaints related to surgical site infection, or evaluating the impact and effectiveness of related quality improvement initiatives.
Type: Yes/no
Can you demonstrate that your hospital has implemented quality improvement activities related to the appropriate use of surgical antibiotic prophylaxis? (SSA_D9)
Answer Yes or No. The HQCC may request further information about the quality improvement activity.
Type: Yes/no
Potential data sources
- Surgical Safety Checklist Australia & New Zealand Edition
- Clinical incident reporting system (e.g. PRIME, RiskMonitorPro, RiskMan)
- Operating room management information system (ORMIS, HBCIS-TMS)
- Pre-operative checklist
- Anaesthetic record
- Transition II
- Patient chart
- Laboratory report