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2014 CAMC Surgical Site Infection (SSI) Worksheet
Patient name Last:
MR #:
First:
Acct # Procedure:
*Gender:
F M
Acct # Infection:
*Event Type: SSI
*Date of Birth:
*NHSN Procedure Code:
*Date of Event (last date to complete criteria):
*Date of Procedure:
*Outpatient Procedure: Yes No
*Date Admitted to Facility (for procedure):
Medicare ID#
Hosp:
*Detected:
□ A (During admission)
□ P (Post-discharge surveillance) □ RF (Readmission to facility
where procedure performed)
□ RO (Readmission to facility other than where procedure was performed)
**Died: Yes No
SSI Contributed to Death: Yes No
Discharge Date (for procedure):
Event Details
Surgeon:
Anesthesiologist:
*Specific Event:
□ Superficial Incisional Primary (SIP) 
□ Superficial Incisional Secondary (SIS)
□ Deep Incisional Primary (DIP)
□ Deep Incisional Secondary (DIS)
□ Organ/Space (specify site): ______________________
BONE – Osteomyelitis
BRST – Breast abscess or mastitis
CARD - Myocarditis or pericarditis
DISC – Disc space
EAR – Ear, mastoid
ENDO – Endocarditis
EMET- Endometritis
EYE – Eye, other than conjunctivitis
GIT – GI tract
HEP – Hepatitis
IAB – Intraabdominal, not specified
elsewhere
IC - Intracranial, brain abscess or
dura
JNT – Joint or bursa
LUNG – Other infections of the
respiratory tract
MED – Mediastinitis
MEN – Meningitis or ventriculitis
ORAL – Oral cavity (mouth, tongue,
or gums
OUTI – Other infections of the urinary
tract
OREP- Other infections of the male
and female reproductive tract
PJI- Periprosthetic Joint
infection
SA – Spinal abscess
SINU – Sinusitis
UR – Upper Respiratory tract
VASC – Arterial or venous
infection
VCUF – Vaginal cuff
SSI Criteria
Superficial incisional SSI
Deep Incisional SSI
Date
Date
Must meet the following criterion:
Infection occurs within 30 days after any NHSN operative
procedure *, including those coded as ‘OTH’*
AND Involves only skin and subcutaneous tissue of the
incision
* (where day 1= the procedure date)
Must meet the following criterion:
Infections occurs within 30 or 90 days after the
NHSN operative procedure* according the list in
Table 1
AND involves deep soft tissue of the incision (e.g.,
fascial and muscle layers)
* (where day 1= the procedure date)
AND Patient has at least one of the following:
AND Patient has at least one 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. Superficial incision that is deliberately opened by
a surgeon, attending physician**, or other designee
and is culture-positive or not cultured
and
Patient has at least one of the following signs or
symptoms (CIRCLE): pain or tenderness;
localized swelling; redness; or heat.
A culture negative finding does not meet this
criterion.
a. Purulent drainage from the deep incision
b. A deep incision that spontaneously
dehisces or is deliberately opened by a
surgeon, attending physician**, or other
designee and is culture-positive or not
cultured
and
Patient has at least one of the following
signs or symptoms: fever (>38o); localized
pain or tenderness.
A culture-negative finding does not meet this
criterion
** Attending physician may be interpreted as: Surgeon,
infectious disease, other physician on case, emergency
physician,physican assistant or nurse practitioner.
** Attending physician may be interpreted as: Surgeon, infectious
disease, other physician on case, emergency physician,physican
assistant or nurse practitioner.
c. An abscess or other evidence of infection
involving the deep incision that is detected
on direct examination, during invasive
procedure, or by histopathologic
examination or imaging test.
d. Diagnosis of a superficial incisional SSI by the
surgeon or attending physician
Reporting Instructions: The following do not qualify as criteria for
meeting the NHSN definition of superficial SSI

A stitch abscess alone (minimal inflammation and discharge confined to
the points of suture penetration)

A localized stab wound or pin site infection. 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.

Diagnosis of “cellulites”, by itself, does not meet Criterion d for superficial
incisional SSI
Reporting Instructions:

Classify infections that involve both superficial and deep incisional
sites as deep incisional SSI.
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


If the superficial incisional infection extends into the fascial and/or muscle
layers, report as a deep incisional SSI only
Circumcision is not an NHSN operative procedure. An infected
circumcision site is classified as CIRC and is not reportable under this
module.
An infected burn wound is classified as BURN and is not reportable under
is module.
Date
Must meet the following Criteria

Classify infection that involves superficial incisional, deep incisional,
and organ/space sites as deep incisional SSI. This is considered a
complication of the incision.
Organ/Space SSI
Reporting Instructions:
Infection occurs within 30 or 90 days after the NHSN
operative procedure* according to the list in Table 1
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
If a patient has an infection in the organ/space being operated on,
subsequent continuation of this infection type during the remainder of the
surveillance period is considered an organ/space SSI, if organ/space SSI
and site-specific infection criteria are met.
* (where day 1= the procedure date)
If meningitis (MEN) and a brain abscess (IC) are present together after
operation, report as SSI-IC. Similarly, if meningitis and spinal abscess
(SA) are present together after an operation, report as SSI-SA.
Report mediastinitis following cardiac surgery that is accompanied by
osteomyelitis as SSI-MED rather than SSI-BONE.
Report CSF shunt infection as SSI-MEN if it occurs within 90 days of
placement; if later or after manipulation/access, it is considered CNSMEN and is not reportable under this module.
AND Patient has at least one of the following:
a.
Purulent drainage from a drain that is placed
into the organ/space
b.
Organisms isolated from an asepticallyobtained culture of fluid or tissue in the
organ/space
An abscess or other evidence of infection
involving the organ/space that is found on
direct examination, during invasive procedure,
or by histopathologic examination or imaging
test.
c.
AND Meets at least one criterion for a specific organ/space
infection site listed on page one.
Procedure Codes:
Organ space Site Specific Definition:
Laboratory – Pathogens identified – attach culture and sensitivity
Culture Site:
□ culture result
□ Positive blood culture ___________________________
_______ of _______ bottles
□ Blood culture not done or no organisms detected in blood
Secondary Bloodstream Infection: Yes No
Comments Notes:
Culture date:
Culture result:
□ Not cultured
□ Positive Gram stain when culture is negative or not done
□ Other positive laboratory tests
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Additional Information:
Start _____________ Stop _______________ Time ______________
Preoperative Antibiotics (dose and time) __________________________
ASA________________
Redose of Antibiotics if time of procedure requires:__________________
Class______________
Antibiotic Allergy: ____________________________________________
Anesthesia ______________________
*Incisional closure type: Primary / Non-Primary Closure
Height ( cm) _______________
Glucose: 1st Intra op: _____________________________
Weight (kg)________________
Emergency:
Yes
No
Endoscope/Robotic: Yes
Diabetic :
Yes
Highest Intraop: __________________________
Trauma Yes
No
No
No
Highest 1st day post op: ____________________
Highest 2nd day post op: ____________________
Hair removal ____________________________
Scrub _________________________________
There are two specific Types of Superficial incisional SSIs:
1.
2.
SIP – a superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more
incisions (e.g., C—section or chest incision for CBGB)
SIS – a superficial incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one
incision (e.g. donor site incision for CBGB)
There are two specific Types of Deep incisional SSIs:
1. DIP – a deep incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisions
(e.g., C—section or chest incision for CBGB)
2. DIS – a deep incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one
incision (e.g. donor site incision for CBGB)
Secondary BSI

Blood and site culture match:
o If the criterion met for the primary infection site requires a culture, then at least one organisms form that site must match and
organisms in the blood culture (antibiograms- of isolates do not have to match).

Only a blood culture – no site culture:
o If the criterion met (may or may not require a positive blood culture) for the primary infection site does not require a culture
and the blood isolate is a logical pathogen for the site, report as a secondary BSI.

Blood and Site Culture do not match:
o If the site-specific culture is an element used to meet the infection site criterion and the blood isolate is also an element used
to meet another criterion at the same infection site, then the BSI is considered secondary to that site-specific infection
o If the site-specific culture is an element used to meet the infection site criterion and the blood isolate is not, then the BIS is
considered a primary infection

Negative Site-specific culture and positive Blood culture:
o If a culture from the suspected site of infection is no growth, but a blood specimen collected as part of the work-up is positive,
that BSI is only considered a secondary BSI if another of the site specific criteria that includes positive blood culture as an
element is met. Otherwise, the BSI is considered a primary BSI, even if another criterion for that site is met and the blood
isolate is a logical pathogen for the infection.
Note: Blood and site-specific specimens do not have to be collected on the same day but their collection dates must be such that they are
considered part of the diagnostic work-up for the infection in question.
* New Incisional Closure Type Definitions:
o Primary Closure: closure of all tissue levels during the original surgery, regardless of the presence of wires, wicks, drains,
or other devices or objects extruding through the incision. This category includes surgeries where the skin is closed by
some means, including incisions that are described as “loosely closed” at the skin level. Thus, if any portion of the incision
is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery.
o Non-Primary Closure: closure that is other than primary and includes surgeries in which the superficial layers are left
completely open during the original surgery and therefore cannot be classified as having primary closure. For surgeries with
non-primary closure, the deep tissue layers may be closed by some means (with the superficial layers left open) or the
deep and superficial layers may both be left completely open. The NHSN protocol includes numerous examples; but in
short, anything not meeting the definition of primary closure is by default non-primary closure.
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Table 1. Surveillance Period for Deep Incisional or Organ/ Space SSI Following Selected NHSN Operative Procedure Categories. Day 1= the date of the
procedure
30- day Surveillance
Code
Operative Procedure
Code
Operative Procedure
AAA
Abdominal aortic aneurysm repair
LAM
Laminectomy
AMP
Limb amputation
LTP
Liver transplant
APPY
Appendix surgery
NECK
Neck surgery
AVSD
Shunt for dialysis
NEPH
Kidney surgery
BILI
Bile duct, liver or pancreatic surgery
OVRY
Ovarian surgery
CEA
Carotid endarterectomy
PRST
Prostate surgery
CHOL
COLO
Gallbladder surgery
Colon surgery
REC
SB
Rectal surgery
Small bowel surgery
CSEC
Cesarean surgery
SPLE
Spleen surgery
GAST
Gastric surgery
THOR
Thoracic surgery
HTP
Heart transplant
THYR
Thyroid and/or parathyroid surgery
HYST
Abdominal hysterectomy
VHYS
Vaginal hysterectomy
KTP
Kidney transplant
XLAP
Exploratory laparotomy
OTH
Other operative procedure not
included in the NHSN categories.
90- day Surveillance
BRST
Breast surgery
CARD
Cardiac surgery
CBGB
Coronary artery bypass graft with both chest and donor site incisions
CBGC
Coronary artery bypass graft with chest incision only
CRAN
Craniotomy
FUSN
Spinal fusion
FX
Open reduction of fracture
HER
Herniorrhaphy
HPRO
Hip prosthesis
KPRO
Knee prosthesis
PACE
Pacemaker surgery
PVBY
Peripheral vascular bypass surgery
RFUSN
Refusion of spine
VSHN
Ventricular shunt