1. Surgical Site Infection Surveillance NHSN Procedure-Associated Module November 10, 2011
Eve Giannetta, RN BSN UVAHS
Kathy Bailey, RN CIC Centra Health System
Janis Ober, RN BSN CIC VCUHS

2. CMS Requirements
This slide shows a screenshot of the current and proposed HAI reporting requirements to CMS as of August The requirements are listed by HAI event, facility type(s) affected, and reporting start date.

3. Settings
Surveillance will occur with surgical patients in any inpatient/outpatient setting where the selected NHSN operative procedure(s) are performed.

4. Requirements COLO Colon Surgery HYST Abdominal hysterectomy
Indicate these on the Patient Safety Monthly Reporting Plan
Collect numerator and denominator data on all selected procedure categories

5. Definitions An NHSN operative procedure is a procedure
That is performed on a patient who is an NHSN inpatient or an NHSN outpatient;
NHSN Inpatient: A patient whose date of admission to the healthcare facility and the date of discharge are different calendar days.
NHSN Outpatient: A patient whose date of admission to the healthcare facility and date of discharge are the same calendar day.

6. Definitions An NHSN operative procedure is a procedure
Takes place during an operation
Defined as a single trip to the operating room (OR) where a surgeon
makes at least one incision through the skin or mucous membrane, including laparoscopic approach
and
closes the incision before the patient leaves the OR

7. Definitions
NOTE:
If the skin incision edges do not meet because of wires or devices or other objects extruding through the incision, the incision is not considered primarily closed and therefore the procedure is not considered an operation.
Further, any subsequent infection is not considered a surgical site infection

8. Definitions Operating Room (OR):
A patient care area that met the Facilities Guidelines Institute’s (FGI) or American Institute of Architects’ (AIA) criteria for an operating room when it was constructed or renovated.
This may include an operating room, C-Section room, interventional radiology room, or a cardiac catheterization lab.

9. Definitions An NHSN operative procedure is a procedure
That is included in Table 1.
COLO Colon Surgery
Incision, resection, or anastomosis of the large intestine; includes large-to-small and small-to-large bowel anastomosis;
Does not include rectal operations
ICD-9 codes: , 17.39, 45.03, 45.26, 45.41, 45.49, 45.52, , 45.79, , , 46.03, 46.04, 46.10, 46.11, 46.13, 46.14, 46.43, 46.52, 46.75, 46.76, 46.94
HYST Abdominal hysterectomy
Abdominal approach with uterine removal
ICD-9 codes 68.31, 68.39, 68.41, 68.49, 68.61, 68.69
Table 1. NHSN Operative Procedure Category Mappings to ICD-9-CM Codes located on NHSN website at

10. Case Finding - Numerator
Numerator Data: All patients having the selected operative procedure are monitored for signs of SSI. The Surgical Site Infection (SSI) form (CDC ) is completed for each such patient found to have an SSI.
NOTES:
If a patient has several NHSN operative procedures prior to an infection, report the operative procedure code of the operation that was performed most closely in time prior to the infection date, unless there is evidence that the infection is associated with a different operation.
NHSN data collection forms (in PDF and customizable formats), including the SSI forms, are located on the NHSN website at Under “NHSN Forms by Component”, click on “Patient Safety Forms”, and scroll down to “Procedure-Associated Module SSI and PPP Forms” to view and/or print out your desired forms.

11. Case Finding - Numerator
If a procedure from more than one NHSN operative procedure category was done through a single incision, attempt to determine the procedure that is thought to be associated with the infection.
If it is not clear (as is often the case when the infection is a superficial incisional SSI), or if the infection site being reported is not an SSI, use the NHSN Principal Operative Procedure Category Selection Lists (Table 3) to select which operative procedure to report.
Table 3. NHSN Principal Operative Procedure Category Selection Lists is located on the NHSN website at

12. Case Finding - Numerator
This slide shows a screenshot of the a NHSN principal operating procedure category selection list. Operative procedures with the highest risk of SSI are listed before those with a lower risk. Example: small bowel surgery is priority #1 and colon surgery is priority #6.
If small bowel and colon surgery done through same incision, report as a SB infection, not a COLO
If ovarian surgery and hysterectomy performed, would be considered a HYST
If CSEC and HYST are performed, would be considered a CSEC

13. Case Finding - Denominator
Denominator Data: For all patients having a procedure selected for surveillance during the month, complete the Denominator for Procedure form (CDC ). The data are collected individually for each operative procedure performed during the month specified on the Patient Safety Monthly Surveillance Plan . The Instructions for Completion of Denominator for Procedure form (Tables of Instructions, Table 13) includes brief instructions for collection and entry of each data element on the form.
NHSN data collection forms (in PDF and customizable formats), including the Denominator for Procedure form, are located on the NHSN website at Under “NHSN Forms by Component”, click on “Patient Safety Forms”, and scroll down to “Procedure-Associated Module SSI and PPP Forms” to view and/or print out your desired forms.
The Table of Instructions is located on the NHSN website at

14. Case Finding - Denominator
If procedures in more than one NHSN operative procedure category are performed during the same trip to the OR even if performed through the same incision, a Denominator for Procedure record is reported for each operative procedure being monitored. For example, if a CARD and CBGC are done through the same incision, a Denominator for Procedure record is reported for each.
If procedures of different ICD-9-CM codes from the same NHSN Operative Procedure Category are performed through the same incision, record only one procedure for that category.

15. Case Finding
Must review your OR procedure list to determine which procedures map to ICD-9 procedure codes included in HYST and COLO procedure categories (and any others you choose to follow)
There is an ICD-9/CPT code crosswalk to assist
NHSN has a complete list of ICD-9 codes with their mapping
NHSN has provided a map of ICD-9-CM procedure Codes to the NHSN operative procedure categories which can be found on the NHSN website at Scroll down to “NHSN Codes and Variables” and click on “ICD9-CM Procedure Code Mapping to NHSN Operative Procedure Categories”. This is an Excel file with many pages which you can navigate by using the tabs on the bottom left side of the Excel window.

16. OR Procedure List
This slide has a screenshot of various colon-related procedures by name. It shows that there are several colon procedures (such as total proctocolectomy) that do not fit NHSN criteria for a colon procedure.

17. Data Entry/Upload
Denominator Data for all procedures may be entered manually or imported electronically
All required fields must be populated in order to successfully upload electronic data file
Requires collaboration with your OR Information Technology Department
May require additional data collection by OR staff
Resources on NHSN website

18. Identifying and Recording Surgical Site Infections
Examples of SSI data sources include but are not limited to: microbiology reports, OR schedules, return to OR reports, readmission lists, chart review of patients with selected surgical procedures, surgeon queries.
Consistently adhere to the NHSN surveillance definitions for SSIs.

19. Superficial SSI Defined
A superficial incisional SSI (SIP or SIS) must meet the following
criterion:
  Infection occurs within 30 days after the operative procedure
and involves only skin and subcutaneous tissue of the incision
and patient has at least 1 of the following:
a. purulent drainage from the superficial incision.
b. organisms isolated from an aseptically obtained culture of fluid
or tissue from the superficial incision.
c. at least 1 of the following signs or symptoms of infection: pain
or tenderness, localized swelling, redness, or heat, and
superficial incision is deliberately opened by surgeon and is
culture positive or not cultured. A culture-negative finding does
not meet this criterion.
d. diagnosis of superficial incisional SSI by the surgeon/attending.

20. Types of Superficial SSIs
Superficial incisional primary (SIP): a superficial incisional SSI that is identified in the primary incision in a patient who has had an operation with 1 or more incisions (eg, C-section incision or chest incision for coronary artery bypass graft with a donor site [CBGB]).
Superficial incisional secondary (SIS): a superficial incisional SSI that is identified in the secondary incision in a patient who has had an operation with more than 1 incision (eg, donor site [leg] incision for CBGB).

21. Reporting Instructions for Superficial SSIs
Do not report a stitch abscess (minimal inflammation and discharge confined to the points of suture penetration) as an infection.
Do not report a localized stab wound infection as SSI. While it would be considered either a skin (SKIN) or soft tissue (ST) infection, depending on its depth, it is not reportable under this module.
“Cellulitis”, by itself, does not meet the criteria for Superficial Incisional SSI. If the incisional site infection involves or extends into the fascial and muscle layers, report as a deep incisional SSI.
Classify infection that involves both superficial and deep incision sites as deep incisional SSI.

22. Deep SSI Defined
A deep incisional SSI must meet the following criterion: Infection occurs within 30 days after the operative procedure if no implant* is left in place or within 1 year if implant* is in place and the infection appears to be related to the operative procedure and involves deep soft tissues (eg, fascial and muscle layers) of the incision and patient has at least 1 of the following: a. purulent drainage from the deep incision but not from organ/space component of the surgical site. b. a deep incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured when the patient has at least 1 of the following signs or symptoms: fever (38oC), or localized pain or tenderness. A culture-negative finding does not meet this criterion. c. an abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination. d. diagnosis of a deep incisional SSI by a surgeon or attending MD.

23. Implant Porcine or synthetic heart valves Mechanical heart Metal rods
A nonhuman-derived object, material or tissue that is permanently placed in a patient during an operative procedure and is not routinely manipulated for diagnostic or therapeutic purposes.
Porcine or synthetic heart valves
Mechanical heart
Metal rods
Mesh
Sternal wires
Screws
Cements
Internal staples
Hemoclips
Non-absorbable sutures are excluded because Infection Preventionists may not easily identify and/or differentiate the soluble nature of suture material used.

24. Types of Deep SSIs
Deep incisional primary (DIP): a deep incisional SSI that is identified in a primary incision in a patient who has had an operation with one or more incisions (eg, C-section incision or chest incision for CBGB)
Deep incisional secondary (DIS): a deep incisional SSI that is identified in the secondary incision in a patient who has had an operation with more than 1 incision (eg, donor site [leg] incision for CBGB).

25. Reporting Instructions for Deep SSIs
Classify infection that involves both superficial and deep incision sites as deep incisional SSI.

26. Organ/Space SSI Defined
An organ/space SSI involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure. Specific sites are assigned to organ/space SSI to identify further the location of the infection.

27. Organ/Space SSI Defined
An organ/space SSI must meet the following criterion:
Infection occurs within 30 days after the operative procedure if no implant* is left in place or within 1 year if implant* is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure
and patient has at least 1 of the following:
 a. purulent drainage from a drain that is placed through a stab wound into the organ/space.
b. organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space.
c. an abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination.
d. diagnosis of an organ/space SSI by a surgeon or attending physician.

28. Organ/Space SSI Specific Sites
Specific sites are assigned to organ/space SSIs to further identify the location of the infection.
Example: Report colon procedure with subsequent abdominal abscess as an organ/space SSI at the intraabdominal specific site (SSI-IAB).

29. Specific Sites of an Organ/Space SSI
BONE
Osteomyelitis
JNT
Joint or bursa
BRST
Breast abscess or mastitis
LUNG
Other infections of the respiratory tract
CARD
Myocarditis or pericarditis
MED
Mediastinitis
DISC
Disc-space
ORAL
Oral cavity
EAR
Ear, mastoid
OREP
Other reproductive tract
EMET
Endometritis
OUTI
Other urinary tract
ENDO
Endocarditis SA
Spinal abscess without meningitis
EYE
Eye, other than conjunctivitis
SINU
Sinusitis
GIT
GI tract UR
Upper respiratory tract
IAB
Intraabdominal, NOS
VASC
Arterial or venous IC
Intracranial, brain abscess or dura
VCUFF
Vaginal cuff

30. Reporting Instructions for Organ/Space SSIs
Occasionally an organ/space infection drains through the incision. Such infection generally does not involve reoperation and is considered a complication of the incision. Therefore, classify it as a deep incisional SSI.

31. Related NHSN Published FAQs
Q: If an abdominal hysterectomy is performed but the uterus is removed through the vagina, is this still reported as an abdominal hysterectomy (HYST) for surgical site infection (SSI) reporting in the NHSN, or should it be recorded as a vaginal hysterectomy (VHYS)?
A: This surgery should be reported as an abdominal hysterectomy. The updated manual which will be released as part of the v6.4 release of NHSN has new descriptions for both of these procedures. The categorization is based on the approach of the surgery, not how the uterus is removed. A hysterectomy with an abdominal approach is reported as a HYST, and a hysterectomy with a vaginal approach is reported as a VHYS.

32. Related NHSN Published FAQs
Q: Is an intraabdominal infection that develops secondary to an anastamotic leak a complication of surgery, or a Surgical Site Infection (SSI)?
A: Both. Any infection that develops following an operative procedure and meets the SSI criteria is indeed an SSI. In the above instance, the anastamotic leak may have been the reason that the infection developed, but if the patient had not had the surgery, there would not have been an anastamotic leak.

33. Related NHSN Published FAQs
Q: Are Hemoclips considered implants in NHSN?
A: We consider hemoclips to be implants because they are non-human derived objects that are permanently placed in patients during surgery and are not routinely manipulated. However, we recognize that identifying their use for surveillance purposes presents a unique challenge to most Infection Preventionists because hemoclip use may not be routinely documented in operative procedures records. We believe this issue may be worth discussing with your OR staff.

34. Related NHSN Published FAQs
Q: Is an “infected hematoma” in a postoperative wound an SSI?
A: The fact that wounds can be labeled in various ways by different physicians is the reason that criteria rather than labels are used for determination of healthcare-associated infections in NHSN. A wound described as an infected hematoma, may indeed meet the criteria for a superficial or deep incisional SSI and should be identified as such if appropriate.

35. Related NHSN Published Clarification
Use of Endoscopy (Laparoscopy) in Hysterectomy Procedures
In the case of a laparoscopic hysterectomy, the uterus is removed with the help of a morcellator. This instrument allows the surgeon to remove a large uterus through a small incision. ICD-9-CM codes for laparoscopic hysterectomy procedures are included within the NHSN operative procedure categories of HYST (abdominal hysterectomy) and VHYS (vaginal hysterectomy).
If the hysterectomy procedure was performed using a laparoscope and the uterus was removed either through the small incision or through the vagina, be sure to indicate “Yes” for the Endoscope field response. Check “No”, if the laparoscopic incision was extended to allow for the insertion of the surgeon’s hand.