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30-Day Post-Operative Colon Surgery (COLO) and Abdominal Hysterectomy (HYST) Surgical Site Infection (SSI) Standardized Infection Ratio (SIR)

CBE ID
0753
Endorsement Status
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
Yes
Next Maintenance Cycle
Spring 2025
1.6 Measure Description

Annual risk-adjusted standardized infection ratio (SIR) of observed over predicted deep incisional primary and organ/space surgical site infections (SSIs), over a 30-day post-operative surveillance period, among hospitalized adults who are >=18 year of age with a date of admission and date of discharge that are different calendar days, and the patient underwent a colon surgery (COLO) or abdominal hysterectomy (HYST) at an acute care hospital or oncology hospital.  The 30-day postoperative surveillance period includes SSIs detected upon admission to the facility or a readmission to the same facility or a different facility (other than where the procedure was performed) and via post-discharge surveillance.

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.10 Measure Rationale

The use of this measure will promote surgical site infection (SSI) prevention activities that will lead to improved patient outcomes including a reduction of SSIs, avoidable medical costs, and patient morbidity and mortality through a reduced need for antimicrobials and reduced length of stay. 

1.25 Data Source Details

NHSN Standard Infection Ratio (SIR) Guide: https://www.cdc.gov/nhsn/2022rebaseline/analysis-resources.html

https://www.cdc.gov/nhsn/acute-care-hospital/ssi/index.html


Surgical Site Infection Event (SSI): https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
Surgical Site Infection (SSI) Event Form: https://www.cdc.gov/nhsn/forms/57.120_SSI_BLANK.pdf
Denominator for Procedure Form: https://www.cdc.gov/nhsn/forms/57.121_DenomProc_BLANK.pdf
2024 ICD-10-CS Procedure Code Mapping to NHSN Operative Procedure Codes: https://www.cdc.gov/nhsn/xls/icd10-pcs-pcm-nhsn-opc.xlsx
2024 Current Procedural Terminology (CPT) Procedure Code Mapping to NHSN Operative Procedure Codes: https://www.cdc.gov/nhsn/xls/cpt-pcm-nhsn.xlsx