Surgical Site Infection Surveillance
HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Surgical Site Infection
Surveillance
Last updated 2019
Basics of Infection Prevention
Healthcare-Associated Infections Program
Center for Health Care Quality
California Department of Public Health
HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Objectives
? Discuss importance of accurate data collection in calculating
surgical patient probability of SSI
? Discuss use of ICD-10 diagnostic ¡°flag¡± codes to improve SSI
case finding
? Review SSI surveillance definitions and methods
? Demonstrate how to report SSI data in NHSN
? Discuss NHSN data analysis and feedback to staff
2
HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
SSI Surveillance Requirements
?
Capture sufficient risk factor data for each procedure
?
Consistently use standard surveillance methods and
definitions to identify SSI
?
?
For CA hospitals, CDPH developed a standardized SSI
surveillance approach using diagnosis codes to flag
potential SSI
Use risk adjusted methods that calculate an SSI probability
for each surgical event
3
HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Surgical Procedure Definition
NHSN operative procedures
? Inpatient = admission and discharge dates on different days
? Take place in an operating room
? Involve at least one incision (including laparoscopic) made
through the skin or mucous membrane, or reoperation via
an incision that was left open during a prior operative
procedure
? Full definition in the NHSN Operative Procedure Category
Mappings to ICD-10-CM Codes and CPT Codes
NHSN Patient Safety Manual: Chapter 9
4
HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Reporting Procedure Denominator Data
? When multiple procedures codes are performed during the
same surgery, each procedure code must be reported
separately in the denominator data
Example: if surgery was performed on the colon and the small
bowel during the same operation, both COLO and SB
procedures should be reported
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