Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection

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Appendix A. Teleconferences with AHRQ & CDC

Improving the Measurement of Surgical Site Infection (SSI) Risk Stratification and Outcome Detection

Monthly Teleconference
Tuesday, 17 November 2009; 12:00 MST

Participants: CDC Technical advisors: Sandra Barrios, Teresa Horan, Jonathan Edwards Project Team: Lucy Savitz, Connie Price, Mike Rubin, Makoto Jones, Jason Scott, Susan Moore

The focus of this call was to review our progress report and to review the final work plan. A summary of points covered is reviewed below.

Progress Report
- Task 4
  - OMB clearance not needed for focus groups.
  - Identified target meeting for focus group at the Academic Surgical Congress in February 2010.
- Task 2
  - Mapping ICD-9 codes to CPT codes—Mike and Mikoto are continuing to work on the mapping
    - CDC would like to see the mapping when available.
- Task 1
  - Monthly conference calls are set-up for the third Tuesday of every month at 12:00 MST (Next call 15 December).
  - First face-to-face meeting is scheduled for Friday, 20 November at IH.
  - Subcontracts with organizations are progressing.
Work Plan
- Resolution matrix was included in the updated work plan to clearly specify how the research team addressed the comments and recommendations from the CDC technical experts and AHRQ TOO.
- Connie Price explained the rationale for covering herniorrhaphy (HER) over colon surgery because HER is more elective and allows for more pre-op opportunity to modify SSI risk; and many states, including Colorado, are reporting SSI cases for herniorrhaphy; further, it allows us to examine a relatively common and often outpatient surgery.
- Sandra Barrios questioned the timing of the focus groups and validating the risk factors.
  - Lucy will revise the work plan to clarify the timing and relationship of the tasks.

Next meeting: 15 December 2009, 12:00 MST

Monthly Teleconference
Tuesday, 15 December 2009; 12:00 MST

Clarification of the list of risk factors
- The list should include all risk factors—modifiable and non-modifiable

Overall Project Status update

Task 2
- Review of ICD-9 and CPT codes to complete mapping.
- In the process of forming a data dictionary.
- Working with Scott Evans to identify data elements from IH algorithm.
- SLCVAH has received approval from the VA security officer to participate as planned.
Task 3
- A timeline is being created and reviewed to facilitate the steps necessary leading-up to the focus groups.
- In review of the initial list of risk facts from Walt Biffl, Scott Evans has added an ‘EMR’ column to indicate of it is currently available in the EMR; and he has added a ‘Define’ column to indicate the need to clarify the definition of the risk factor.
- Literature search from 2008 – current was conducted-
  - PubMed keyword search: "SSI risk factors"
- Scott is compiling a list of additional risk factors based on a review of abstracts defining and listing SSI risk factors.
Task 4
- Walt Biffl is planning the focus group to include 10 – 12 surgeons at the Academic Surgical Congress, in February.
  - The focus group will review current accepted risk stratification models and review the list of new risk factors.
  - The group will evaluation additional risk factors not in the list and provide feedback relevant to the factors being modifiable vs. non- modifiable.
Task 1/5
- During the meeting at IH, the group review and coordinated the responsibilities across the organizations.

Action item

The CDC/AHRQ team requested a contact list of individuals involved in the project.

Susan and Jason will coordinate and distribute the complete list to the CDC/AHRQ team.

Monthly Teleconference
Tuesday, 19 January 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Proposed Agenda

Introductions

Overall Project Status update

Task 2
- Review of the algorithm prototype and data dictionary.
Task 3
- The list of identified risk factors is being reviewed and will begin review by each organization to determine availability in EMR.
Task 4
- A room for the focus group has been reserved and 4 participants are currently confirmed.
- Susan and Lucy are preparing a guide for the focus group.
Task 1/5 – Administrative

Other items?

Next scheduled call: 16 February 2010 - 14:00 EST; 12:00 MST
*agenda and any reference materials will be sent on 12 February 2010 due to Presidents’ Day holiday on 15 February 2010

Monthly Teleconference
Tuesday, 19 January 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Participants: AHRQ Task Order Officer: Kendall Hall
CDC technical advisors: Sandra Barrios, Teresa Horan
Project Team: Lucy Savitz, Connie Price, Mike Rubin, Makoto Jones, Jason Scott, Susan Moore, Scott Evans, Russ Staheli

Overall Project Status update

Task 2
- Makoto reviewed the algorithm prototype and data dictionary
  - The CDC/AHRQ team had concerns regarding the algorithm being driven off of positive cultures.
    - The plan is to progress with the current algorithm for a test set then review the gaps and look at other work to pick-up any events initially missed.
Task 3
- The list of identified risk factors is to include all factors—including modifiable/non modifiable, measurable/non measurable; and will begin review by each organization to determine availability in EMR
  - Each organization is beginning review of the list of risk factors and will have EMR availability results to the group by 5 February 2010.
Task 4
- A room for the focus group has been reserved and 4 participants are currently confirmed
  - The CDC/AHRQ team requested a list of specialties of the focus group participants
    - Once all participants for the focus group have been confirmed, Susan will compile and submit this information.
  - Susan and Lucy are preparing a guide for the focus group.
  - A focus group of OR nurses is being planned at Intermountain Healthcare.
  - Plan is submitted for expedited IRB review.
Task 1/5 – Administrative
- Subcontract between Denver Health and SLCVAH is complete.
- Subcontract between Denver Health and Intermountain Healthcare is near complete.
- Intermountain Healthcare is working to get Privacy Board approval for use of de-identified data.
- SLCVAH has received Privacy Board approval for use of de-identified data.

Next scheduled call: 16 February 2010 - 14:00 EST; 12:00 MST
*agenda and any reference materials will be sent on 12 February 2010 due to Presidents’ Day holiday on 15 February 2010

Monthly Teleconference
Tuesday, 16 March 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Proposed Agenda

Introduction

Overall Project Status update

Task 2
- Review of updated algorithm and process to begin testing.
Task 3
- Progress update of risk factor organization review.
Task 4
- Follow-up discussion of focus group.
- Focus group summary.
Task 1/5
- Administrative.

Additional items, questions/concerns, or comments.

Next call:
20 April, 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 16 April 2010

Monthly Teleconference
Tuesday, 16 March 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Notes

Attendees:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisor: Sandra Barrios
Project Team: Lucy Savitz, Susan Moore, Mike Rubin, Walt Biffl, Scott Evans, Jason Scott

Overall Project Status update

Task 2
- Review of updated algorithm and process to begin testing
  - Data collection phase will begin at Salt Lake City VA and Intermountain Healthcare immediately following IRB approval.
    - NSQIP data will be used initially to train the algorithm and test availability.
    - Following initial training and testing at Salt Lake City VA and Intermountain Healthcare, the algorithm is expected to undergo adjustments based on data results before system wide testing.
Task 3
- Progress update of risk factor organization review
  - The list of common risk factors and availability is near complete and will be distributed immediately following completion.
Task 4
- Follow-up discussion of focus group
- Focus group summary
  - The draft Provisional Content Analysis of the focus group was reviewed.
    - Although the inclusion of nonmodifiable factors was considered ‘inappropriate’ by the focus group, nonmodifiable factors will be included for testing.
      - The concern of nonmodifiable factors is a point of comment, not exclusion.
    - The ranking of risk factors includes ‘Feasible’ criteria, which indicates the ability to access the data electronically; while ‘Feasible, Difficult’ would require manual review to obtain the data.
      - The lower ranking factors are not criteria for exclusion from testing. All identified risk factors will be tested in the algorithm.
    - Based on preliminary review, Sandra indicated no apparent omission from the list of risk factors
      - Sandra will review the list with Teresa and Jonathan and communicate any concerns to the group.
Task 1/5
- Administrative
  - All sub contracts are complete.

______________________________

Next call:
20 April, 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 16 April 2010

Monthly Teleconference
Tuesday, 20 April 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Proposed Agenda

Introduction

Overall Project Status update

Task 2
- Review of process to begin algorithm testing and training.
Task 3
- Review if master risk factor list.
- Review of process for writing program to collect and pool data.
Task 4
- Focus group content analysis update.
Task 1/5
- Administrative.

Additional items, questions/concerns, or comments.

Next call:
18 May 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 14 May 2010

Monthly Teleconference
Tuesday, 20 April 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Notes

Attendees:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisors: Sandra Barrios, Jonathan Edwards, Teresa Horan
Project Team: Susan Moore, Mike Rubin, Scott Evans, Connie Price, Jason Scott

Overall Project Status update

Task 2
- Review of process to begin algorithm testing and training
  - Collecting VA data (NSQIP) will begin data collection with IH immediately following IRB approval from IH.
Task 3
- Review if master risk factor list
  - Master risk factor list is complete.
  - All variables identified as "depends on definition" are being defined by ICD-9 definitions.
- Review of process for writing program to collect and pool data
  - Meeting with Risk Adjustment Group is being planned for May 18
    - Will develop spreadsheet for each site to use.
      - Make sure to differentiate between not knowing, and not having the factors available (“0”)
    - Request to include Jonathan in the Risk adjustment Group meeting via telephone for the May 18 meeting
      - Jason will send meeting information/call-in information to Jonathan.
Task 4
- Focus group content analysis update.
  - Finishing content analysis.
Task 1/5
- Administrative
  - Subcontracts are finalized.
  - Billing process for IH and SLCVA are in progress.

Next call:
18 May 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 14 May 2010

Monthly Teleconference
Tuesday, 18 May 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Proposed Agenda

Introduction

Overall Project Status update

Task 2
- Review of algorithm testing and training
Task 3
- Review and update of master risk factor list.
- Review of program development to collect and pool data.
- Risk adjustment meeting
  - Today; 15:00 (Eastern), 13:00 (Mountain).
Task 4
- Focus group content analysis update.
Task 1/5
- Administrative.

Additional items, questions/concerns, or comments.

Next call:
15 June 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 11 June 2010

Monthly Teleconference
Tuesday, 18 May 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Notes

Attendees: AHRQ Task Order Officer: Kendall Hall
CDC technical advisors: Sandra Barrios, Jonathan Edwards, Teresa Horan
Project Team: Lucy Savitz, Walt Biffl, Susan Moore, Mike Rubin, Scott Evans, Connie Price, Jason Scott

Overall Project Status update

Task 2
- Review of algorithm testing and training.
Task 3
- Review and update of master risk factor list
  - Coding for procedures
    - ICD-9:
      - for each admit—store primary code.
      - Use of decimals in the code?
        
        Decimals should be included
        
        Each organization will verify use of decimals in EMR
    - Duration of Surgery factor is measured in minutes from incision to closure.
- Review of program development to collect and pool data
  - Scott is working on a common spreadsheet template for each organization to record the data
    - Each row of the spreadsheet will record a separate surgery.
  - Each organization will look at the common risk factors.
    - There will also be a sub analysis of all the risk factors available at Intermountain Healthcare.
    - Kendall requested a list of variables unique to each organization.
- Risk adjustment meeting
  - Today; 15:00 (Eastern), 13:00 (Mountain)
Task 4
- Focus group content analysis update
  - Susan and Walt have finished review of provisional analysis
    - No follow-up items determined.
    - Final review will be available at next meeting.

Action Items:

Complete list of all variables unique to each organization.

Next call:
15 June 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 11 June 2010

Monthly Teleconference
Tuesday, 15 June 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Proposed Agenda

Introduction

Overall Project Status update

Task 3
- Review risk adjustment meeting
- Updated master risk factor list
Task 4
- Meeting held to review final themes of surgeon focus group
Task 1/5
- Administrative

Additional items, questions/concerns, or comments.

Next call:
20 July 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 16 July 2010

Monthly Teleconference
Tuesday, 15 June 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Notes

Attendees:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisors: Sandra Barrios, Jonathan Edwards
Project Team: Susan Moore, Mike Rubin, Scott Evans, Connie Price, Jason Scott

Introduction

Overall Project Status update

Task 3
- Review risk adjustment meeting
  - Handling of missing variables
    - Once frequencies are available the need to impute values will be determined.
  - Multiple procedures for the same patient will be included
- Updated master risk factor list
  - Anemia
    - The inclusion of the measured value of hemoglobin will be more useful than a yes/no value of anemia
      - yes/no anemia values can be derived from the measured values based on set criteria to be used in the analyses of SSI risk factors.
    - Check with Walt regarding the inclusion of preop and postop hemoglobin levels.
  - DVT
    - Measure of DVT can determine the use of anticoagulants which contributes to the risk of hematoma.
    - Check with Walt regarding the inclusion of DVT as a measure of SSI risk factors.
  - Antibiotics
    - Measure of antibiotic use should be broken into two factors
      - Preop antibiotic use
      - Preop antibiotic DC timing
        
        Cardiac surgeries have DC time of 48 hrs.
        
        All other surgeries have DC time of 24 hrs.
Task 4
- Meeting held to review final themes of surgeon focus group
  - The final content analysis is being completed and will be available before the next call.
Task 1/5
- Administrative
  - IRB & Privacy Board review are continuing at Intermountain and Denver.

Additional items, questions/concerns, or comments.

Next call:
20 July 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 16 July 2010

Monthly Teleconference
Tuesday, 20 July 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Proposed Agenda

Introduction

Overall Project Status update

Task 3
- Review of data collection process for common risk factors.
- Outstanding items discussion.
Task 4
- Final content analysis of surgeon focus group
Task 1/5
- Administrative

Additional items, questions/concerns, or comments.

Next call:
17 August 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 13 August 2010

Monthly Teleconference
Tuesday, 20 July 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Notes

Attendees:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisors: Sandra Barrios, Teresa Horan
Project Team: Susan Moore, Lucy Savitz, Scott Evans, Connie Price, Jason Scott

Introduction

Overall Project Status update

Task 2
- Gold standard question
  - Testing the electronic algorithm against the NSQIP dataset.
    - The rigor of the surveillance with NSQIP is more complete than the collection at most sites.
      - Tested at SLCVAMC and Intermountain
        
        Intermountain only collects on one procedure
  - Options
    - Use national VA data
      - Not diverse population
      - Difficult to get permission to use national data
    - Use of VA NSQIP and IH data
  - Any concerns with using IP collected data
    - If the algorithm is being designed to replace the typical IP system, it should be to base it off of typical IP collection.
    - It can be validated against the different systems and verify against NSQIP (SLCVAMC) and Intermountain.
  - Subset analysis of perioperative deep wound/organ space infections
Task 3
- Review of data collection process for common risk factors
  - IH has reviewed all common risk factors and identified several elements that could be problematic to collect reliably.
    - IH has completed provisional analyses of ~ 20,000 patients
  - Denver has begun collection of data and will report with any trouble elements.
- Outstanding items discussion
  - Postop hemoglobin has been added to the risk factor list
  - Abx dx – 48 for CABG, and 24 for all others
    - need to add into risk factors table
  - Hypocholesterolemia – TYPO? Instead of Hyper?—
    - Hypocholesterolemia was determined as a risk factor by the surgeon focus group as an indication of poor wound healing
  - Anemia-follow-up on collection of value—the collection of the value is possible instead of just a yes/no.
Task 4
- Final content analysis of surgeon focus group
  - The usefulness of the focus group outcomes:
    - The process of the focus group can be considered and discussed in the final report
      - Validity check
      - engaging the surgeon group
      - Capturing factors the team may not have considered.
Task 1/5
- Administrative
  - IRB & Privacy Board approval pending at Denver and Intermountain

Additional items, questions/concerns, or comments.

Next call:
17 August 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 13 August 2010
--There may be a potential conflict with this call.
Sandra and Teresa will check their schedules and contact Susan to reschedule if necessary

Monthly Teleconference
Tuesday, 21 September 2010 - 13:00 EST; 11:00 MST
Call-in number: 888-342-6631; code: 2414#

Proposed Agenda

Introduction

Overall Project Status update

Task 2
- Salt Lake City VA has the data to begin creating the rules for the algorithm.
Task 3
- Data collection is taking place within each organization
Task 4
Task 1/5
- In-person team meeting scheduled
  - 15 October 2010 in Salt Lake City
    - Project officer invite to participate via videoconference.

Additional items, questions/concerns, or comments.

Next call:
17 August 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 13 August 2010

Monthly Teleconference
Tuesday, 21 September 2010 - 13:00 EST; 11:00 MST
Call-in number: 888-342-6631; code: 2414#

Notes

Attendees:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisor: Teresa Horan
Project Team: Lucy Savitz, Susan Moore, Scott Evans, Jef Huntington, Makoto Jones, Pat Nechodom, Jason Scott

Introduction

Overall Project Status update

Task 2
- Salt Lake City VA has the data to begin creating the rules for the algorithm.
  - NSQIP data will be used to train the algorithm with older data and tested with newer data
  - IRB has been approved for expanded VA data
- Task 2 team meeting is scheduled for October 4th.
Task 3
- Data collection is taking place within each organization
  - All variables have been finalized
  - Intermountain has collected data and is preparing for analysis
  - All organizations are in the process of collecting data
    - Collected data will be sent to Jeff Huntington at Intermountain
    - Susan will follow up with Connie to get data collection progress from Vail.
Task 1/5
- In-person team meeting scheduled
  - 15 October 2010 in Salt Lake City
    - Project officer and technical advisors are invited to participate via videoconference or telephone from 3:00 - 4:00 PM EST
      - Susan will send invitations to the project officer and technical advisors for participation mode (video or telephone).

Next call:
19 October 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 18 October 2010

Monthly Teleconference
Tuesday, 30 November 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Proposed Agenda

Introduction

Overall Project Status update

Task 2
- NSQIP data collection at Salt Lake City VA Medical Center—including national VA NSQIP data
Task 3
- Program development and data analysis at Intermountain
- Data collection at other systems
- Development of table to indicate where each system had the data for each risk factor.
Task 4
- Repurposed nursing focus group to present use cases for response.
  - Denver (Mile High APIC)
  - Salt Lake City
Task 1/5
- Final in-person team meeting scheduled for 28 January 2011 in Vail, Colorado

Additional items, questions/concerns, or comments.

Next call:
21 December 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 17 December 2010

Monthly Teleconference
Tuesday, 30 November 2010 - 14:00 EST; 12:00 MST
Call-in number: 866-266-7337; code: 489038#

Notes

Attendees:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisor: Teresa Horan, Sandra Barrios, Jonathan Edwards
Project Team: Lucy Savitz, Susan Moore, Connie Price, Heather Gilmartin, Jef Huntington, Makoto Jones, Jason Scott

Introduction

Overall Project Status update

Task 2
- NSQIP data collection at Salt Lake City VA Medical Center—including national VA NSQIP data
  - All data (local and national VA NSQIP) has been collected
  - Analysis has begun
    - There are some discrepancies with the start dates of the data
      - SLC VA is working to clean the data
    - Algorithm is in the development process
    - National projection
      - Numbers are small with about 20 total outcomes from documented SSI events
      - There was a discussion of strength of national projections based on the population mix of the VA data as well as the small numbers
        
        The measures will be validated using SLC VA data as well as Intermountain data from all hospitals
        
        The projections, with validation, are expected to accurately represent regional projections, and with the inclusion of national VA data have national validity
Task 3
- Data collection at other systems
  - Denver Health is completing the data collection
    - There are a few elements that have been difficult to collect, and a meeting is set up within Denver Health to complete the collection of the remaining elements
  - Vail has begun collection and will complete the pull following the collection at Denver Health and Intermountain
  - SLC VA has pulled all data elements
Task 4
- Repurposed nursing focus group to present use cases for response to be held at Denver (Mile High APIC) and Salt Lake City.
  - 1st draft of focus group protocol is complete and will be included in the December report
    - A meeting with Intermountain and Denver Health is planned to review the draft.
  - The focus group dates have not yet been set
    - The results of the data analyses of the project are expected to be presented at the focus groups
      - Once data analysis is complete, focus group dates will be set—likely in February.
  - An abstract has been submitted to SHEA
    - The abstract will be sent the AHRQ & CDC in the next monthly report.
    - No cost extension is likely denied
      - Meeting attendance as a part of dissemination may not be possible as part of the project.
    - Susan will inquire about the possibility of registering for conferences prior to the end of the contract.
Task 1/5
- Final in-person team meeting scheduled for 28 January 2011 in Vail, Colorado as a writing retreat for the draft final report.
  - Draft final report will be submitted by 15 February 2011.
  - Final report will be submitted 11 March 2011.

Next call: 21 December 2010; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 17 December 2010
- The call may have to be rescheduled based on availability of the group.

More information to come.

Monthly Teleconference
Tuesday, 28 December 2010 - 14:00 EST; 12:00 MST
Call-in number: 866-266-7337; code: 134690#

Proposed Agenda

Introduction

Overall Project Status update

Task 2
- National VA NSQIP data analysis.
- Algorithm development.
Task 3
- Program development and data analysis at Intermountain.
- Development of table to indicate where each system had the data for each risk factor.
Task 4
- Repurposed nursing focus group to present use cases for response.
  - First focus group will assess and develop workflow of current SSI surveillance and the resources for process change implementation
  - Second focus group will assess workflow from first group and address the resources and workflow for process change implementation.
  - Both focus groups are planned to be held in January
    - Denver (Mile High APIC)
    - Salt Lake City
- Updates on conference presentations
Task 1/5
- Final in-person team meeting scheduled for 27-28 January 2011 in Vail, Colorado as a writing retreat for the draft final report.
  - Draft final report will be submitted to AHRQ by 11 February 2011
  - Final report will be submitted to AHRQ 11 March 2011

Additional items, questions/concerns, or comments.

Next call:
18 January 2011; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 14 January 2011

Monthly Teleconference
Tuesday, 28 December 2010 - 14:00 EST; 12:00 MST
Call-in number: 866-266-7337; code: 134690#

Notes

Attendees:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisor: Teresa Horan, Sandra Barrios
Project Team: Lucy Savitz, Susan Moore, Connie Price, Heather Gilmartin, Mike Rubin, Jason Scott

Introduction

Overall Project Status update

Task 2
- National VA NSQIP data analysis complete
  - Mike will send the results of the analysis to Susan to distribute.
- Algorithm development
  - Currently working to get the data into a usable format for the algorithm
Task 3
- Program development and data analysis at Intermountain
  - The program is being developed using Intermountain and Denver Health data
  - The program will be updated as data from other sites come in
    - Vail is expecting to have data available early January
    - SLC VA is working to finish collection
- Development of table to indicate where each system had the data for each risk factor.
  - The process of data collection is being carefully documented to identify data sources as well as the decision making process to use one data source over another
- There have been no surprises from the data collection process except for the varied sources of data—which, as indicated, are being thoroughly documented.
Task 4
- Repurposed nursing focus group to present use cases for response.
  - First focus group will assess and develop workflow of current SSI surveillance and the resources for process change implementation
    - A mockup flowchart will be presented for the group to respond to.
  - Second focus group will assess workflow from first group and address the resources and workflow for process change implementation.
  - Both focus groups are planned to be held in January
    - Denver (Mile High APIC)
    - Salt Lake City
  - Generalizability of results
    - The focus groups are expected to have representation from at least 6 different systems
    - The groups will be looking at the process of an electronic surveillance tool
    - The focus groups are expected to raise some interesting and useful questions about the adoption and use of the surveillance tool as well as process challenges
- Updates on conference presentations
  - SHEA abstract was accepted
  - Abstract submitted to SIS
  - Susan will send both abstracts to AHRQ & CDC
Task 1/5
- The request has been submitted to the contracting officer to pay for dissemination including all costs associated with conference registrations, travel to conferences, journal submissions (e-journal: Implementation Science)
  - The request was made to pay for such dissemination efforts prior to the end of the contract period.
- Final in-person team meeting scheduled for 27-28 January 2011 in Vail, Colorado as a writing retreat for the draft final report.
  - Jonathan expressed interest in attending the meeting
    - Susan will look into reserving a room at the hotel for him and confirm with him in early January
- Draft final report will be submitted to AHRQ by 11 February 2011
  - The report has been outlined and sections have been assigned.
  - Sections will be completed mid-January
  - The sections will be integrated to be worked on at the January 27-28 meeting
  - A ‘Lessons Learned’ section will be included in the report
- Final report will be submitted to AHRQ 11 March 2011

Next call:
18 January 2011; 14:00 EST; 12:00 MST
*agenda and reference materials will be sent on 14 January 2011

Monthly Teleconference
Tuesday, 19 January 2010 - 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Participants:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisors: Sandra Barrios, Teresa Horan
Project Team: Lucy Savitz, Connie Price, Mike Rubin, Makoto Jones, Jason Scott, Susan Moore, Scott Evans, Russ Staheli

Overall Project Status update

Task 2
- Makoto reviewed the algorithm prototype and data dictionary
  - The CDC/AHRQ team had concerns regarding the algorithm being driven off of positive cultures.
    - The plan is to progress with the current algorithm for a test set then review the gaps and look at other work to pick-up any events initially missed.
Task 3
- The list of identified risk factors is to include all factors—including modifiable/non modifiable, measurable/non measurable; and will begin review by each organization to determine availability in EMR
  - Each organization is beginning review of the list of risk factors and will have EMR availability results to the group by 5 February 2010.
Task 4
- A room for the focus group has been reserved and 4 participants are currently confirmed
  - The CDC/AHRQ team requested a list of specialties of the focus group participants
    - Once all participants for the focus group have been confirmed, Susan will compile and submit this information.
  - Susan and Lucy are preparing a guide for the focus group
  - A focus group of OR nurses is being planned at Intermountain Healthcare
  - Plan is submitted for expedited IRB review
Task 1/5 – Administrative
- Subcontract between Denver Health and SLCVAH is complete.
- Subcontract between Denver Health and Intermountain Healthcare is near complete.
- Intermountain Healthcare is working to get Privacy Board approval for use of de-identified data.
- SLCVAH has received Privacy Board approval for use of de-identified data.

Next scheduled call: 16 February 2010 - 14:00 EST; 12:00 MST
*agenda and any reference materials will be sent on 12 February 2010 due to Presidents’ Day holiday on 15 February 2010

Monthly Teleconference
Monday, 31 January 2011 - 10:00 EST; 8:00 MST
Call-in number: 888-342-6631; code: 2414#

Meeting Notes

Attendees:
AHRQ Task Order Officer: Kendall Hall
CDC technical advisor: Sandra Barrios
Project Team: Lucy Savitz, Susan Moore, Scott Evans, Connie Price, Mike Rubin, Makoto Jones, Jef Huntington, Jason Scott

Overall Project Status update

Task 2
- Algorithm training
  - National VA NSQIP data is being used to identify the small set of electronically available variables that contribute most to the detection of SSI using recursive partitioning.
    - A hybrid system is planned—to use the algorithm as a surveillance tool to trigger reduced burden of manual review by ICPs
    - Deep tissue & organ space surveillance vs inclusion of superficial infections
      - It was proposed to focus the algorithm on deep tissue and organ space infection to increase the sensitivity and minimize false positives of the surveillance tool.
      - The algorithm is still expected to pick up some superficial infections, but the tool would be honed to pick up the more clinically relevant complex infections.
      - Sandra asked if CABG is divided into sternal and harvest subgroups as superficial infections are more common in harvest procedures.
      - The data will be evaluated to look at sternal vs harvest CABG.
    - Sandra asked if burden estimates can be evaluated to look at the algorithm with all SSI inclusions vs just complex
      - We need to document what is lost by tuning the algorithm to deep wound and organ space infections
      - Estimates will be evaluated and included in the final report.
    - Kendall asked for a flowchart of the algorithm
      - Mike and Makoto will provide the flowchart, which is generated via the classification tree, and these will be included in the final report as an appendix
  - Determination of burden to implement the algorithm at different sites
    - Each site is documenting the set up and implementation process costs.
    - We expect these to be minimal.
Task 3
- The data from all systems is being incorporated and used to identify key risk factors.
Task 4
- Repurposed nursing focus group to present use cases for response.
  - Focus groups have been exempted by the Intermountain IRB and from OMB clearance review (as the two nursing focus group protocols are distinct and in compliance with OMB rules).
    - Denver—Wednesday, 2 February 2011
      - Getting ICPs from at least 4 systems in the area to explore issues around adoption of the surveillance tool
    - Salt Lake City--TBD
      - ICPs for multiple systems will explore issues around implementation of the surveillance tool
    - Lucy is working to recruit participants for the 2nd focus group, which is intended to iteratively follow focus group 1 (results from group 1 inform discussion in group 2)
  - The outputs of the focus groups will be used to create a user manual and include at least 2 use cases.
Task 5
- Draft final report will be delivered electronically by 11 February 2011
  - The report will be in Word format and the appendices will be PDFs
  - The draft report will also be submitted through ARRS
- Updates on conference presentations/dissemination.
  - Kendall submitted a dissemination plan to include attendance and presentation at SHEA, SIS, Academy Health, and the AHRQ Annual Meeting. Publications were also included in the plan.
- Discussion of sustained tool implementation and development
  - Sandra discussed the importance of making sure the tool is viewed by adopting systems to be dynamic (vs. static)) continually evolving and will QI/QA with continuing feedback to support improvement and continued applicability of the tool.
  - Kendall asked how we plan to keep a feedback loop.
    - Feedback recommendations will be made in the report
    - Denver Health is planning to use the tool and modify it to include other surgeries.
    - Adoption at SLC VAMC would likely show applicability in VAs nationwide—Mike will explore a connection with the VA National Center for Patient Safety as suggested by Kendalll
    - Lucy will connect with the AHRQ Health Care Innovations Exchange to explore how we might monitor and track uptake.
Task 1
- The call scheduled on 15 February 2011 was proposed to be postponed one week to allow time for AHRQ & CDC to provide feedback from the draft report
  - Susan will poll the group to reschedule the call
- Invoicing
  - Systems are working with their accounting departments for updated invoices and final invoicing to be submitted on time.

Next call: To be determined, on or about 2/22/11. Susan will get dates and times to reschedule

Monthly Teleconference
Tuesday 15 March 2011 – 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Notes

Attendees:
AHRQ: Kendall Hall
CDC: Teresa Horan, Sandra Barrios Jonathan Edwards
Project Team: Susan Moore, Lucy Savitz, Jason Scott, Jef Huntington, Mike Rubin, Makoto Jones, Connie Price, Walt Biffl, Heather Gilmartin

General project updates
- No cost extension granted through October 2011 for dissemination
  - Project work planed to be finished in April
- The algorithm is being run at each site multiple times
  - Specificity is very low (many false negatives)
  - Doing extensive chart reviews to learn more about the e surveillance
    - Looking for elements that were not picked-up, but present in charts (specifically false negatives)
    - Determine factors leading to false negatives
- Task three work is continuing and will use additional time for QA of code
- Task 4: focus groups complete.
  - Generating a universal user manual
Dissemination plans
- AMIA-abstract due 17 February
- What should be submitted to AHRQ and CDC prior to dissemination?
  - AHRQ and CDC would like to review abstracts for dissemination activities
Additional items
- Connie and Jonathan with arrange time at the SHEA meeting to have a group discussion
  - Will include a detailed review of the algorithm development process.

Monthly Teleconference
Tuesday 19 April 2011 – 14:00 EST; 12:00 MST
Call-in number: 888-342-6631; code: 2414#

Notes

Attendees:
AHRQ: Kendall Hall
CDC: Teresa Horan, Jonathan Edwards
Project Team: Susan Moore, Lucy Savitz, Jason Scott, Jef Huntington, Scott Evans, Mike Rubin, Connie Price, Walt Biffl

General project status review
- Task 2 - Algorithm testing and site chart reviews
  - Details of the algorithm development were reviewed at SHEA meeting.
  - Chart reviews are done at SLCVAMC and Denver Health—Intermountain chart reviews will be completed following template update based on Denver Health feedback.
    - Issues found with data format
      - Looking at where the data come from and how it was coded
    - The variation in data across all systems will be an important factor to note in the final report
- Task 3 – data analyses update
  - Code has been verified and will run data (including SLC VAMC) by the end of the week
    - Scott write up report
Additional items
- User manual—pulling documentation across all tasks to inform the manual
- Data from nursing focus groups will be included in the next monthly report
- Final report is being updated based on new work as it comes along
- Extending the work to other surgeries eg, colon, hysterectomy
  - The work could not be an extension of this contract as it is a change in the scope of the work—it will require an add-on of an additional project.
    - Kendall will discuss this question at AHRQ and gauge feasibility of an add-on project
    - Teresa will talk to Sandra about possibility of support from CDC

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