SSI Bundle Data Collection Fields
Compilation of 20 Canadian Hospital data collection sheets April 5, 2012
General Information
Date Completed: (D/M/Y) ________________________ ICP: _______________
Patient Name: (Last) ________________________ (First) ____________________
HSN: ______________________________ MRN: ________________________
Sex: M
F
DOB: (D/M/Y) _______________________________
Admission Date: ___________________ Hospital: ____________ Unit: ______________
Patient Contact Number: ______________________________________________
Service:
THO
CSX
CVT
GSU
Is the CDC criteria for SSI met: Yes
GYN
NSX
OBS
ORT
PLA
No
Infection Date Onset: _________________________________
Confirmed Infection Site:
Superficial
Signs and Symptoms: Purulent Drainage
Micro Report:
Yes
No
Deep
Organ/Space
Fever
Odor Pain
Site: ___________________
Redness
Swelling
Culture Result: ______________________________________________
Surgical Information
Patient point of entry to OR: Emergency Pre-op In patient
Patient comorbities (Check all that apply) Diabetes COPD Ischemic Heart Disease
Procedure Date: (D/M/Y) _______________ OR Theatre: _________
Pre-op Diagnosis: _____________Readmit due to Surgical Infection: Yes
No
Date: ________________
Surgeon: ______________________________ Surgical Procedure: __________________________
Laproscopic Yes No
Open Yes No
Procedure Start: __________ Procedure End: _______________________ Total Time: ______________
Incision (Wound) Class: Clean (class I); Clean-Contaminated (class II) ; Contaminated (class III);
Dirty (class IV)
Anesthetists Name: ________________________ ASA Score: 1
Implant:
Yes
2
3
4
Not filled in
No
Devices
Catheter Type
SSI Data Fields Compilation_April 5_2012.docx
Start
T.Rollefstad
End
Ventilated
Central Line
Start
Start
End
End
ABX Timing & Discontinuation Fields
Yes  No
Any allergies to Antibiotics?
Was Antibiotic completed within 60 minutes pre-incision:
Yes
No
Time of Incision____________________________________hrs
Is there any tissue damage at incision site i.e. burn, rash, infection?
Yes
□ No
Tourniquet start time ____________ hours
Name of Drug Time Administered ___________________hrs
 Cefazolin/Ancef
 Clindamycin
 Other, specify _____________________________________
(Above drugs to be given within 0-60 minutes prior to incision)


Vancomycin
Fluoroquinolone
(Above drugs to be given within 0-120 minute prior to incision)
Vancomyacin 2 hours Pre-Op: Yes
No
ABX Redose after 4 hours (after first dose)
ABX given_____________ Time of completion ____________
Emergency Class: 1
2
3
No
Prophylactic Antibiotics: Yes
No
Antibiotic discontinued within 24 hours after surgery end time. Yes  No
Were instruments flash-sterilized
Yes
No
Skin Prep Fields
OR Skin Prep: Chlorhexidine
CHG Pre Op bath: Y
Betadine Other: _________________________
N
Hair Removal Fields
Hair Removal: Yes
No Razor: Yes
No Same Day: Yes
Method of Hair Removal
 Clipper
 No Hair Removal
 Razor
SSI Data Fields Compilation_April 5_2012.docx
T.Rollefstad
No

Depilatory (waxing, neet) if yes was it done closer than 1 week of surgical date? Yes No
Location:
 Home
 SDC/Ward
 OR
Normothermia Fields
Is patient's temperature >= 36.0 degrees C on arriving to OR Yes  No
Temperature _________________degrees C (Tympanic Temporal Core)
Is patient's temperature >= 36.0 degrees C at incision time in OR Yes  No
Temperature _________________degrees C (Tympanic Temporal Core)
Is patient's temperature >= 36.0 degrees C on leaving OR Yes  No
Temperature _________________degrees C (Tympanic Temporal Core)
Is patient's temperature >= 36.0 degrees C on arrival in PARR Yes  No
Tympanic Temperature _________________degrees C (Tympanic Temporal
Core)
Interventions Check (√) all that apply
 Fluid warmer
 Upper blanket warmer
 Lower blanket warmer
 Leg warmer
 Maximum drapes
 Socks
 Hat/toque/head warming
 Limiting skin exposure transfer to stretcher
Is there a pre-existing infection that would affect temperature i.e. pneumonia, UTI
Comment _____________________________________________________________________
Glucose Control Fields
Glucose ≤ 10mmol/L:
Yes
No
Pre-op glucose: ______ Post Op Glucose :Day One: ________ Day Two:______
If >11.1 glucose control implemented: Y
N
What method of glucose control taken?
 Insulin ggt
 Sliding scale SC Insulin
 Oral
SSI Data Fields Compilation_April 5_2012.docx
T.Rollefstad
Yes
□ No