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2014 CAMC Surgical Site Infection (SSI) Colon Worksheet
Patient name Last:
First:
*Gender: F M
*Event Type: SSI
*NHSN Procedure Code:
*Date of Procedure:
*Date Admitted to Facility (for procedure):
*Detected:
□ A (During admission)
30 days
MR #:
Acct # Procedure:
Acct # Infection:
*Date of Birth:
*Date of Event (last date to complete criteria):
*Outpatient Procedure: Yes No
Medicare ID#
Hosp:
□ RF (Readmission to
□ P (Post-discharge surveillance)
facility where
procedure performed)
□ RO (Readmission to facility other than where procedure was performed)
**Died: Yes No
Event Details
SSI Contributed to Death: Yes
No
Discharge Date (for procedure):
Surgeon:
Anesthesiologist:
*Specific Event:
□ Superficial Incisional Primary (SIP) 
□ Deep Incisional Primary (DIP)
□ Superficial Incisional Secondary (SIS)
□ Deep Incisional Secondary (DIS)
□
Organ/Space (specify site): _______________________
IAB – Intraabdominal, not specified elsewhere
GIT – GI tract
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
AND Patient has at least one of the following:
a. Purulent drainage from the superficial
incision
b. Organisms isolated from an asepticallyobtained 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.
** Attending physician may be interpreted as: Surgeon,
infectious disease, other physician on case, emergency
physician,physican assistant or nurse practitioner.
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)
Must meet the following criterion:
Infections occurs within 30 after the NHSN
operative procedure
AND
involves deep soft tissue of the incision (e.g.,
fascial and muscle layers)
AND Patient has at least one of the following:
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 culturenegative 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.
c. An abscess or other evidence of
infection involving the deep incision that
is found on direct examination, during
invasive procedure, or by
histopathologic examination or imaging
test.
Reporting Instructions:
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
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

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.
If the superficial incisional infection extends into the fascial and/or muscle
layers, report as a deep incisional SSI only
Date
Must meet the following Criteria


Classify infections that involve both superficial and deep incisional
sites as deep incisional SSI.
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 days after the NHSN operative
procedure
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
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
c. 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.
AND Meets at least one criterion for a specific
organ/space infection site listed.
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
Occasionally an organ/space infection drains through the incision and
is considered a complication of the incision. Therefore, classify it as a
deep incisional SSI.
IAB-Intraabdominal infection, not specified elsewhere including
gallbladder, bile ducts, liver (excluding viral hepatitis), spleen,
pancreas, peritoneum, subphrenic or subdiaphragmatic space, or
other intraabdominal tissue or area not specified elsewhere
GIT-Gastrointestinal tract infection (esophagus, stomach, small and
large bowel, and rectum) excluding gastroenteritis and appendicitis
Gastrointestinal tract infections, excluding gastroenteritis and
appendicitis, must meet at least 1 of the following criteria:
1.
Patient has an abscess or other evidence of infection seen
during an invasive procedure or histopathologic
examination.
2. Patient has at least 2 of the following signs or symptoms
compatible with infection of the organ or tissue involved:
fever (>38°C), nausea*, vomiting*, abdominal pain*,
tenderness*, or diarrhea*
AND at least 1 of the following:
a. organisms cultured from drainage or tissue
obtained during an invasive procedure or
endoscopy or from an aseptically-placed drain
b.
c.
d.
e.
organisms seen on Gram’s or KOH stain or
multinucleated giant cells seen on microscopic
examination of drainage or tissue obtained
during an invasive procedure or endoscopy or
from an aseptically-placed drain
Intraabdominal infections must meet at least 1 of the following criteria:
1. Patient has organisms cultured from abscess and/
or purulent material from intraabdominal space
obtained during an invasive procedure.
1.
Patient has abscess or other evidence of
intraabdominal infection seen during an invasive
procedure or histopathologic examination.
2.
Patient has at least 2 of the following signs or
symptoms: fever (>38°C), nausea*, vomiting*,
abdominal pain*, or jaundice
AND at least 1 of the following:
a.
organisms cultured from drainage from
an aseptically-placed drain (e.g., closed
suction drainage system, open drain, Ttube drain)
organisms cultured from blood
b.
evidence of pathologic findings on imaging test
c.
organisms seen on Gram’s stain of
drainage or tissue obtained during
invasive procedure or from an
aseptically-placed drain
Organisms cultured from blood and
imaging test evidence of infection (e.g.,
abnormal findings on ultrasound, CT
Evidence of pathologic findings on endoscopic
a.
examination (e.g., Candida esophagitis or
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proctitis, or toxic megacolon)
* With no other recognized cause
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
scan, MRI, or radiolabel scans [gallium,
technetium, etc.] or on abdominal x-ray).
* With no other recognized cause
Culture date:
Culture result:
□ Not cultured
□ Positive Gram stain when culture is negative or not done
□ Other positive laboratory tests
Additional Information:
Start _____________ Stop _______________ Time ______________
(hr&min)
ASA________________
Preoperative Antibiotics (dose and time) _____________________
Class______________
Antibiotic allergies:______________________________________
Anesthesia ______________________
Incision Closure: Primary/ Non-Primary Closure
Height (cm)____________________
Glucose: 1st Intra op: ________________
Weight (kg)________________
Emergency:
Yes
No
Endoscope/Robotic: Yes
Diabetic :
Yes
Redose ( dose and time from prior dose given) _______________
Highest Intraop: ___________________
Trauma Yes
No
No
No
Highest 1st day post op: ____________________
Highest 2nd day post op: ____________________
Hair removal ____________________________
Did patient expire: Yes No
Scrub : _________________________________
COLO – Colon Surgery: 17.31-17.36, 17.39, 45.03, 45.26, 45.41, 45.49,
Incision, resection, or anastomosis of the large intestine; includes
large-to-small and small-to-large bowel anastomosis; does not
include rectal operations
45.52, 45.71-45.76, 45.79, 45.81-45.83, 45.92-45.95, 46.03, 46.04, 46.10,
46.11, 46.13, 46.14, 46.43, 46.52, 46.75, 46.76, 46.94
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.
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* 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.