Facility adjusted Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) for deep incisional and organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients aged >= 18 years as reported through the CDC National Health and Safety Network (NHSN).
Measure Specs
General Information
Numerator
Deep incisional primary (DIP) and organ/space SSIs during the 30-day postoperative period among patients = 18 years of age, who undergo inpatient colon surgeries or abdominal hysterectomies. SSIs will be identified before discharge from the hospital, upon readmission to the same hospital, or during outpatient care or admission to another hospital (post-discharge surveillance).
Numerator Exclusion SSI events with PATOS* field = yes.
Infection present at time of surgery (PATOS): PATOS denotes that there is evidence of an infection or abscess at the start of or during the index surgical procedure (in other words, it is present preoperatively). PATOS is a YES/NO field on the SSI Event form. PATOS does not apply if there is a period of wellness between the time of a preoperative condition and surgery. The evidence of infection or abscess must be noted/documented intraoperatively in an operative note or report of surgery. Only select PATOS = YES if it applies to the depth of SSI that is being attributed to the procedures (e.g., if a patient has evidence of an intraabdominal infection at the time of surgery and then later returns with an organ/space SSI the PATOS field would be selected as a YES. If the patient returned with a superficial or deep incisional SSI the PATOS field would be selected as a NO). The patient does not have to meet the NHSN definition of an SSI at the time of the primary procedure but there must be notation that there is evidence of an infection or abscess present at the time of surgery. PATOS is not necessarily diagnosis driven.
Denominator
An NHSN Operative Procedure is a procedure:
• that is included in the ICD-10-PCS or CPT NHSN operative procedure code mapping. And
• takes place during an operation where at least one incision (including laparoscopic approach and cranial Burr holes) is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure And
• takes place in an operating room (OR), defined as 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.
Exclusions: Otherwise eligible procedures that are assigned an ASA score of 6 are not eligible for NHSN SSI surveillance.
Using multivariable logistic regression models for colon surgeries and abdominal hysterectomies, the predicted number of SSIs is obtained. These predicted numbers are summed by facility and surgical procedure and used as the denominator of this measure (see also 2a.8).
Exclusions
Denominator data are excluded from the SSI measure due to various reasons related to data quality, data outlier and data errors. The complete list of universal exclusion criteria applied to denominator are listed in the SSI section of the SIR guide that is referenced above. These exclusions include but are not limited to procedures associated with SSI events where the PATOS = yes, and those with ASA Class VI (6). The measure specific denominator exclusions for the Complex 30-day SSI, are off plan colon and abdominal hysterectomy procedures, procedures performed on persons under the age of 18, and procedure performed on an outpatient basis. .
Note: Under the 2015 baseline, both primarily closed procedures and those that are not closed primarily are included in the denominator data.Persons under the age of 18, those having a procedure performed on an outpatient basis, procedures associated with SSI events where the PATOS = yes, those with ASA Class VI (6) are excluded.
Note: Both primarily closed procedures and those that are not closed primarily are included in the denominator data.
Measure Record
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