scholarly journals Impact of Postdischarge Surveillance on Surgical Site Infection Rates for Several Surgical Procedures Results From the Nosocomial Surveillance Network in The Netherlands

2006 ◽  
Vol 27 (08) ◽  
pp. 809-816 ◽  
Author(s):  
Judith Manniën ◽  
Jan C. Wille ◽  
Ruud L. M. M. Snoeren ◽  
Susan van den Hof
Keyword(s):  
Medical Record ◽  
Surgical Procedures ◽  
Clinical Symptoms ◽  
Knee Prosthesis ◽  
Surgical Site Infections ◽  
Abdominal Hysterectomy ◽  
Surveillance Network ◽  
Femorotibial Bypass ◽  
Registration Card

Objective. To compare the number of surgical site infections (SSIs) registered after hospital discharge with respect to various surgical procedures and to identify the procedures for which postdischarge surveillance (PDS) is most important. Design. Prospective SSI surveillance with voluntary PDS. Recommended methods for PDS in the Dutch national nosocomial surveillance network are addition of a special registration card to the outpatient medical record, on which the surgeon notes clinical symptoms and whether a patient developed an SSI according to the definitions; an alternative method is examination of the outpatient medical record. Setting. Hospitals participating in the Dutch national nosocomial surveillance network between 1996 and 2004. Results. We collected data on 131,798 surgical procedures performed in 64 of the 98 Dutch hospitals. PDS was performed according to one of the recommended methods for 31,134 operations (24%) and according to another active method for 32,589 operations (25%), and passive PDS was performed for 68,075 operations (52%). Relatively more SSIs were recorded after discharge for cases in which PDS was performed according to a recommended method (43%), compared with cases in which another active PDS method was used (30%) and cases in which passive PDS was used (25%). The highest rate of SSI after discharge was found for appendectomy (79% of operations), followed by knee prosthesis surgery (64%), mastectomy (61%), femoropopliteal or femorotibial bypass (53%), and abdominal hysterectomy (53%). Conclusions. For certain surgical procedures, most SSIs develop after discharge. SSI rates will be underestimated if no PDS is performed. We believe we have found a feasible and sensitive method for PDS that, if patients routinely return to the hospital for a postdischarge follow-up visit, might be suitable for use internationally.

scholarly journals Impact of Postdischarge Surveillance on Surgical Site Infection Rates for Several Surgical Procedures Results From the Nosocomial Surveillance Network in The Netherlands

2006 ◽  
Vol 27 (8) ◽  
pp. 809-816 ◽  
Author(s):  
Judith Manniën ◽  
Jan C. Wille ◽  
Ruud L. M. M. Snoeren ◽  
Susan van den Hof
Keyword(s):  
Medical Record ◽  
Surgical Procedures ◽  
Clinical Symptoms ◽  
Knee Prosthesis ◽  
Surgical Site Infections ◽  
Abdominal Hysterectomy ◽  
Surveillance Network ◽  
Femorotibial Bypass ◽  
Registration Card

Objective.To compare the number of surgical site infections (SSIs) registered after hospital discharge with respect to various surgical procedures and to identify the procedures for which postdischarge surveillance (PDS) is most important.Design.Prospective SSI surveillance with voluntary PDS. Recommended methods for PDS in the Dutch national nosocomial surveillance network are addition of a special registration card to the outpatient medical record, on which the surgeon notes clinical symptoms and whether a patient developed an SSI according to the definitions; an alternative method is examination of the outpatient medical record.Setting.Hospitals participating in the Dutch national nosocomial surveillance network between 1996 and 2004.Results.We collected data on 131,798 surgical procedures performed in 64 of the 98 Dutch hospitals. PDS was performed according to one of the recommended methods for 31,134 operations (24%) and according to another active method for 32,589 operations (25%), and passive PDS was performed for 68,075 operations (52%). Relatively more SSIs were recorded after discharge for cases in which PDS was performed according to a recommended method (43%), compared with cases in which another active PDS method was used (30%) and cases in which passive PDS was used (25%). The highest rate of SSI after discharge was found for appendectomy (79% of operations), followed by knee prosthesis surgery (64%), mastectomy (61%), femoropopliteal or femorotibial bypass (53%), and abdominal hysterectomy (53%).Conclusions.For certain surgical procedures, most SSIs develop after discharge. SSI rates will be underestimated if no PDS is performed. We believe we have found a feasible and sensitive method for PDS that, if patients routinely return to the hospital for a postdischarge follow-up visit, might be suitable for use internationally.

scholarly journals Administrative Coding Methods Impact Surgical Site Infection Rates

2020 ◽  
Vol 41 (S1) ◽  
pp. s111-s112
Author(s):  
Mohammed Alsuhaibani ◽  
Mohammed Alzunitan ◽  
Kyle Jenn ◽  
Daniel Diekema ◽  
Michael Edmond ◽  
...  
Keyword(s):  
Cesarean Section ◽  
Surgical Procedures ◽  
Hip Prosthesis ◽  
Knee Prosthesis ◽  
Surgical Site Infections ◽  
Fold Increase ◽  
Abdominal Hysterectomy ◽  
Absolute Difference ◽  
Coding Method ◽  
The Impact

Background: Surveillance for surgical site infections (SSI) is recommended by the CDC. Currently, colon and abdominal hysterectomy SSI rates are publicly available and impact hospital reimbursement. However, the CDC NHSN allows surgical procedures to be abstracted based on International Classification of Diseases, Tenth Revision (ICD-10) or current procedural terminology (CPT) codes. We assessed the impact of using ICD and/or CPT codes on the number of cases abstracted and SSI rates. Methods: We retrieved administrative codes (ICD and/or CPT) for procedures performed at the University of Iowa Hospitals & Clinics over 1 year: October 2018–September 2019. We included 10 procedure types: colon, hysterectomy, cesarean section, breast, cardiac, craniotomy, spinal fusion, laminectomy, hip prosthesis, and knee prosthesis surgeries. We then calculated the number of procedures that would be abstracted if we used different permutations in administration codes: (1) ICD codes only, (2) CPT codes only, (3) both ICD and CPT codes, and (4) at least 1 code from either ICD or CPT. We then calculated the impact on SSI rates based on any of the 4 coding permutations. Results: In total, 9,583 surgical procedures and 180 SSIs were detected during the study period using the fourth method (ICD or CPT codes). Denominators varied according to procedure type and coding method used. The number of procedures abstracted for breast surgery had a >10-fold difference if reported based on ICD only versus ICD or CPT codes (104 vs 1,109). Hip prosthesis had the lowest variation (638 vs 767). For SSI rates, cesarean section showed almost a 3-fold increment (2.6% when using ICD only to 7.32% with both ICD & CPT), whereas abdominal hysterectomy showed nearly a 2-fold increase (1.14% when using CPT only to 2.22% with both ICD & CPT codes). However, SSI rates remained fairly similar for craniotomy (0.14% absolute difference), hip prosthesis (0.24% absolute difference), and colon (0.09% absolute difference) despite differences in the number of abstracted procedures and coding methods. Conclusions: Denominators and SSI rates vary depending on the coding method used. Variations in the number of procedures abstracted and their subsequent impact on SSI rates were not predictable. Variations in coding methods used by hospitals could impact interhospital comparisons and benchmarking, potentially leading to disparities in public reporting and hospital penalties.Funding: NoneDisclosures: None

scholarly journals Percutaneous Total Endoscopic Resection of Partial Articular Processes for Treatment of Lateral Crypt Stenosis and Lumbar Spinal Stenosis: Technical Report and Efficacy Analysis

2018 ◽  
Vol 2018 ◽  
pp. 1-7
Author(s):  
Fujun Wu ◽  
Weijun Kong ◽  
Wenbo Liao ◽  
Jun Ao ◽  
Sheng Ye ◽  
...  
Keyword(s):  
Spinal Stenosis ◽  
Lumbar Spinal Stenosis ◽  
Clinical Symptoms ◽  
Surgical Site Infections ◽  
Efficacy Evaluation ◽  
Curative Effect ◽  
Single Segment ◽  
Vas Score ◽  
Lumbar Spinal

Objective. To observe the clinical curative effect of posterior total endoscopic precision decompression for the treatment of single-segment lateral crypt lumbar spinal stenosis (LSS). Method. A total of 27 patients with single-segment LSS satisfying the inclusion criteria were recruited from July 2013 to September 2015. There were 18 cases of unilateral stenosis of the L4-5 segments and 9 cases of unilateral stenosis of the L5-S1 segment. All patients were treated via the posterior approach with the precise lateral crypt decompression technique. Precise decompression was performed on the narrow areas causing clinical symptoms. Clinical efficacy was assessed at 3 days, 3 months, 6 months, and 2 years after surgery. Low-back pain and sciatic nerve pain assessed by visual analog scale (VAS) score and the functional Oswestry Disability Index (ODI) were used to evaluate lumbar function, and modified MacNab score criteria were used to investigate long-term efficacy. Result. All patients completed the operation successfully, and the follow-up time was 2 years. The VAS score of lumbago was lower after than before surgery (preoperative: 6.96±0.90; postoperative: 2.04±1.02, P<0.05). The VAS score of sciatica was also lower after than before surgery (preoperative: 7.19±0.88, postoperative: 1.93±0.92, P<0.05), and the ODI was improved at the last follow-up (29.62±4.26) % compared with before surgery (80.07±3.98) %. The MacNab efficacy evaluation showed improvement at the end of the follow-up period: 20 cases were excellent, 6 cases were good, and 1 case was satisfactory, with a good/excellent rate of 96%. No surgical site infections, iatrogenic nerve root injuries, epidural hematomas, or other complications occurred. Conclusion. Total endoscopic decompression of posterior facet arthrodesis for the treatment of single-segment lateral crypt LSS has the advantages of safety, reduced recurrence and trauma, and a satisfactory curative effect. This trial is registered with ChiCTR1800015628.

scholarly journals Clinical features and outcome of fecal retention in infancy

2020 ◽  
Author(s):  
Lu Ren ◽  
Lan-Lan Geng ◽  
hong-li Wang ◽  
si-tang Gong ◽  
Jing Xie ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Clinical Features ◽  
Clinical Symptoms ◽  
Gastrointestinal Symptoms ◽  
Treatment Rate ◽  
Record System ◽  
Significant Difference ◽  
Normal Defecation

Abstract 1) Background: To understand the clinical features and outcome of fecal retention in infancy(FRI), so as to guide the focus and intervention methods of such infants.2) Methods: The electronic medical record system(EMRS)was used to collect and screen out cases diagnosed as fecal retention from June 2018 to June 2019 in outpatient clinic of our hospital. The age, feeding method, frequency and traits of stool, and accompanying symptoms were recorded. The changes of clinical symptoms, medical examinations and drug treatment by the age of 1 year were investigated by means of electronic medical record review and telephone follow-up.3) Results: A total of 286 infants were enrolled, 7 were lost to follow-up, and 279 were effectively followed up. There were 157 males and 129 females, with an age of 3.6 ± 1.5 months. The average stool frequency was 5.9 ± 1.8 days. 63.3% of the infants were breast-fed, 16.8% were formula-fed, and the rest were mixed-fed,all without supplementary food. 9.1% of the infants showed corresponding gastrointestinal symptoms, such as bloating, increased crying, decreased milk intake, and laborious defecation. 87.1% of the infants received medical treatment, including glycerin enema, probiotics, and Chinese herbal preparations, with an effective treatment rate of 7.8%. 38.7% of infants have undergone medical examination, including abdominal ultrasound, X-ray film / barium enema, blood test, etc, the positive rate is 14.8%. The duration of fecal retention in 53% of infants was ≤ 2 months, 22.6% between 2–3 months, 24.4% ≥ 3 months, with an average of 2.6 ± 1.1 months. At the age of followed up to 1 year, 16.8% of infants developed functional constipation(FC). Compared with other infants with normal defecation, there was no significant difference in age, frequency of stool, the proportion of breast milk feeding and receiving treatment, and there was a significant difference in the duration of fecal retention. The duration of FC group was longer than normal defecation group by which was 3.49 ± 0.83 months.4) Conclusions: Infants with fecal retention are more likely to develop FC at age 1 than general population, and may be positively related to the duration of fecal retention.

scholarly journals Analysis of the incidence of surgical site infections after open reposition of long bone fractures and closed fracture settings in a 7-year follow-up in an orthopedic and trauma ward in southern Poland

2020 ◽  
pp. 336-345
Author(s):  
Róża Słowik ◽  
Marta Wałaszek ◽  
Witold Zieńczuk
Keyword(s):  
Bone Fractures ◽  
Risk Index ◽  
Trauma Surgery ◽  
Surgical Site Infections ◽  
Long Bone ◽  
Women Patients ◽  
Surveillance Network ◽  
Healthcare Associated ◽  
And Control

INTRODUCTION. Surgical Site Infection (SSI) is the most common clinical form of Healthcare-Associated Infections (HAI) in orthopedic and trauma wards. MATERIAL AND METHOD. A retrospective study was conducted at the Department of Orthopedics and Trauma Surgery in Tarnów in 2012-2018. 3 155 patients treated for bone fractures were analyzed, including 1961 Open Reduction of Fracture (FX) and 1 194 Closed Reduction of Fracture with Internal Fixation (CR) surgeries. The study was conducted in accordance with the methodology recommended by the Surveillance Network (HAI-Net), European Centre for Disease Prevention and Control (ECDC). The aim of the study was to assess the incidence of SSI in patients undergoing the FX and CR procedures. RESULTS. 28 SSIs were identified in the examined ward; 16 SSI cases related to the FX procedure and 12 cases related to CR. The incidence for FX was 0.8% and for CR 1%. In patients with diagnosed SSI, the stay in the ward was longer (p <0.001) than in patients without SSI. In FX operations, the standardized risk index (SIR) did not exceed the value of one. Staphylococcus aureus was the most common organism isolated from materials from patients with SSI. CONCLUSIONS. In the examined period, the median age of women was higher than that of men, which may indicate a higher incidence of fractures in women. Patients with diagnosed SSI had a longer stay in the ward than patients without SSI. The incidence of SSI in FX and CR has been reduced compared to previous studies in the same ward.

scholarly journals Relevance of Modified Debridement-Irrigation, Antibiotic Therapy and Implant Retention Protocol for the Management of Surgical Site Infections: A Series of 1694 Instrumented Spinal Surgery

2018 ◽  
Vol 3 (5) ◽  
pp. 266-272 ◽  
Author(s):  
Romain Manet ◽  
Tristan Ferry ◽  
Jean-Etienne Castelain ◽  
Gilda Pardey Bracho ◽  
Eurico Freitas-Olim ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Antibiotic Therapy ◽  
Success Rate ◽  
Surgical Procedures ◽  
Spinal Surgery ◽  
Surgical Site Infections ◽  
Second Look ◽  
Implant Retention ◽  
New Surgery

Abstract. Introduction: Management of surgical site infections (SSI) after instrumented spinal surgery remains controversial. The debridement-irrigation, antibiotic therapy and implant retention protocol (DAIR protocol) is safe and effective to treat deep SSI occurring within the 3 months after instrumented spinal surgery.Methods: This retrospective study describes the outcomes of patients treated over a period of 42 months for deep SSI after instrumented spinal surgery according to a modified DAIR protocol.Results: Among 1694 instrumented surgical procedures, deep SSI occurred in 46 patients (2.7%): 41 patients (89%) experienced early SSI (< 1 month), 3 (7%) delayed SSI (from 1 to 3 months), and 2 (4%) late SSI (> 3months). A total of 37 patients had a minimum 1 year of follow-up; among these the modified DAIR protocol was effective in 28 patients (76%) and failed (need for new surgery for persistent signs of SSI beyond 7 days) in 9 patients (24%). Early second-look surgery (≤ 7days) for iterative debridement was performed in 3 patients, who were included in the cured group. Among the 9 patients in whom the modified DAIR protocol failed, none had early second-look surgery; 3 (33%) recovered and were cured at 1 year follow-up, and 6 (66%) relapsed. Overall, among patients with SSI and a minimum 1 year follow-up, the modified DAIR protocol led to healing in 31/37 (84%) patients.Conclusions: The present study supports the effectiveness of a modified DAIR protocol in deep SSI occurring within the 3 months after instrumented spinal surgery. An early second-look surgery for iterative debridement could increase the success rate of this treatment.

Incidence of Surgical-Site Infections and the Validity of the National Nosocomial Infections Surveillance System Risk Index in a General Surgical Ward in Santa Cruz, Bolivia

2003 ◽  
Vol 24 (1) ◽  
pp. 26-30 ◽  
Author(s):  
Lorena Soleto ◽  
Marianne Pirard ◽  
Marleen Boelaert ◽  
Remberto Peredo ◽  
Reinerio Vargas ◽  
...  
Keyword(s):  
Risk Factors ◽  
Surgical Procedures ◽  
Nosocomial Infections ◽  
Risk Index ◽  
Surgical Site Infections ◽  
Santa Cruz ◽  
Surgical Ward ◽  
System Risk ◽  
Local Risk

AbstractObjectives:To estimate the frequency of and risk factors for surgical-site infections (SSIs) in Bolivia, and to study the performance of the National Nosocomial Infections Surveillance (NNIS) System risk index in a developing country.Design:A prospective study with patient follow-up until the 30th postoperative day.Setting:A general surgical ward of a public hospital in Santa Cruz, Bolivia.Patients:Patients admitted to the ward between July 1998 and June 1999 on whom surgical procedures were performed.Results:Follow-up was complete for 91.5% of 376 surgical procedures. The overall SSI rate was 12%. Thirty-four (75.6%) of the 45 SSIs were culture positive. A logistic regression model retained an American Society of Anesthesiologists score of more than 1 (odds ratio [OR], 1.87), a not-clean wound class (OR, 2.28), a procedure duration of more than 1 hour (OR, 1.81), and drain (OR, 1.98) as independent risk factors for SSI. There was no significant association between the NNIS System risk index and SSI rates. However, a “local” risk index constructed with the above cut-off points showed a linear trend with SSI (P < .001) and a relative risk of 3.18 for risk class 3 versus a class of less than 3.Conclusions:SSIs cause considerable morbidity in Santa Cruz. Appropriate nosocomial infection surveillance and control should be introduced. The NNIS System risk index did not discriminate between patients at low and high risk for SSI in this hospital setting, but a risk score based on local cutoff points performed substantially better.

scholarly journals Infections and antibiotic therapy in patients after spine surgery in a 5-year follow-up study

2021 ◽  
Author(s):  
Joanna Baranowska ◽  
Alicja Baranowska ◽  
Paweł Baranowski ◽  
Tadeusz Płusa ◽  
Wojciech Białowąs ◽  
...  
Keyword(s):  
Antibiotic Therapy ◽  
Infection Rate ◽  
Surgical Procedures ◽  
Spinal Surgery ◽  
Surgical Site Infections ◽  
Retrospective Data ◽  
Follow Up Study ◽  
Leading Position ◽  
Extent Of Surgery

IntroductionInfections after spinal surgery are sporadic and depend on the patient's condition and the type and extent of surgery. The incidence of surgical site infections in European centers ranges from 0% to 18%. The aim of the study was to determine the frequency of infections in patients after spinal surgery.Material and methodsThe analysis covered 6067 patients who underwent spinal surgery in the Department of Neuroorthopedics between 2015-2019, taking into account the number of microbiological tests and the number of detected infections, the number of surgical procedures and the rate of SSI infections, the number of readmissions and reoperations, and the use of antibiotics. The analysis was based on retrospective data of patients hospitalized in the analyzed period.ResultsThe number of operated patients remained at a similar level in the analyzed annual periods, from 1136 to 1269 patients, while the infection rate of the operated site ranged from 0,33% to 1,04%, and the percentage of infections was between 0,58% and 3,29 %. In turn, the analysis of reoperations performed due to infection of the operated site in 2018 and 2019 was 0,56% and 0,07%, respectively, which places the center in the leading position in the European ranking. During the analyzed five years, the use of antibiotics was reduced by 2/3.ConclusionsThe analysis of infections in patients after spinal surgery over a 5-year period showed that the SSI rate did not exceed 1,04%, which is comparable with data from recognized European centers. Infections caused by alarm pathogens have been detected occasionally.

scholarly journals Ureteral Obstruction in Endometriosis

2018 ◽  
Vol 13 (2) ◽  
pp. 35-40
Author(s):  
Amit Mani Upadhyay ◽  
Ashok Kunwar ◽  
Sanjesh Shrestha ◽  
Kabir Tiwari ◽  
Hema Kumari Pradhan ◽  
...  
Keyword(s):  
Surgical Procedures ◽  
Preoperative Diagnosis ◽  
Open Surgery ◽  
Uterine Cavity ◽  
Abdominal Hysterectomy ◽  
Ureteric Stent ◽  
Ureteral Endometriosis ◽  
Endometriotic Cyst ◽  
Symptoms And Signs

Aim: Endometriosis is defined as functional endometrial glands and stroma that occur outside the uterine cavity. It is an estrogen dependent, benign, inflammatory disease that affects women during premenarcheal, reproductive and postmenopausal hormonal stages. Methods: This is a retrospective review of six cases with diagnosis of ureteral endometriosis. All the patients were referred to Department of Surgery, Kathmandu Model Hospital and the study period was from September 2015 to August 2018. Results: In our study all the patients had involvement of the ureter. All the patients who had undergone open surgery had extrinsic involvement of the ureter. Two patients who had mild distal ureteric stenosis only were managed by diagnostic URS and retrograde DJ stenting. Another two patients with right distal ureteric stenosis were managed initially with retrograde DJ stenting but after removal of ureteric stent and in subsequent follow up the degree of hydroureteronephrosis increased in both the cases. These two patients were finally undergone right Lich Gregoir ureteroneocystostomy. In the remaining two patients, ureterorenoscopy (URS) guided double J stenting were attempted but failed to insert the stent due to stenosed ureter so they underwent open abdominal hysterectomy with excision endometriotic cyst with ureterolysis and double J stenting. Conclusions: Ureteral endometriosis is a rare disease presenting most commonly with nonspecific symptoms and signs and thus making preoperative diagnosis often difficult for the clinicians. Treatment of ureteral endometriosis is primarily surgical. The surgical procedures which are usually performed are excision of all endometriosis lesion, ureterolysis, ureterectomy with ureteroureteral anastomosis and ureteroneocystomy.

Complex Surgical Site Infections and the Devilish Details of Risk Adjustment: Important Implications for Public Reporting

2008 ◽  
Vol 29 (10) ◽  
pp. 941-946 ◽  
Author(s):  
Deverick J. Anderson ◽  
Luke F. Chen ◽  
Daniel J. Sexton ◽  
Keith S. Kaye
Keyword(s):  
Hip Prosthesis ◽  
Knee Prosthesis ◽  
Risk Index ◽  
Surgical Site Infections ◽  
Abdominal Hysterectomy ◽  
Index Score ◽  
Case Mix ◽  
Infection Surveillance ◽  
Reporting Rates ◽  
Risk Index Score

Objective.To validate the National Nosocomial Infection Surveillance (NNIS) risk index as a tool to account for differences in case mix when reporting rates of complex surgical site infection (SSI).Design.Prospective cohort study.Setting.Twenty-four community hospitals in the southeastern United States.Methods.We identified surgical procedures performed between January 1, 2005, and June 30, 2007. The Goodman-Kruskal gamma or G statistic was used to determine the correlation between the NNIS risk index score and the rates of complex SSI (not including superficial incisional SSI). Procedure-specific analyses were performed for SSI after abdominal hysterectomy, cardiothoracic procedures, colon procedures, insertion of a hip prosthesis, insertion of a knee prosthesis, and vascular procedures.Results.A total of 2,257 SSIs were identified during the study period (overall rate, 1.19 SSIs per 100 procedures), of which 1,093 (48.4%) were complex (0.58 complex SSIs per 100 procedures). There were 45 complex SSIs identified following 7,032 abdominal hysterectomies (rate, 0.64 SSIs per 100 procedures); 63 following 5,318 cardiothoracic procedures (1.18 SSIs per 100 procedures); 139 following 5,144 colon procedures (2.70 SSIs per 100 procedures); 63 following 6,639 hip prosthesis insertions (0.94 SSIs per 100 procedures); 73 following 9,658 knee prosthesis insertions (0.76 SSIs per 100 procedures); and 55 following 6,575 vascular procedures (0.84 SSIs per 100 procedures). All 6 procedure-specific rates of complex SSI were significantly correlated with increasing NNIS risk index score (P< .05).Conclusions.Some experts recommend reporting rates of complex SSI to overcome the widely acknowledged detection bias associated with superficial incisional infection. Furthermore, it is necessary to compensate for case-mix differences in patient populations, to ensure that intrahospital comparisons are meaningful. Our results indicate that the NNIS risk index is a reasonable method for the risk stratification of complex SSIs for several commonly performed procedures.

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