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2014 CAMC Surgical Site Infection (SSI) Hysterectomy 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)
MR #:
Acct # Procedure:
Acct # Infection:
*Date of Birth:
*Date of Event (last date to complete criteria):
*Outpatient Procedure: Yes No
Medicare ID#
Hosp:
□ P (Post-discharge surveillance)
□ RF (Readmission to
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
Surgeon:
Discharge Date (for procedure):
Anesthesiologist:
*Specific Event:
□ Superficial Incisional Primary (SIP) 
□ Deep Incisional Primary (DIP)
□ Superficial Incisional Secondary (SIS)
□ Deep Incisional Secondary (DIS)
□
Organ/Space (specify site):
_______________________
30 days
IAB – Intraabdominal, not specified elsewhere
OREP-Other infection of the male or female
reproductive tract
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)
* (where day 1= the procedure date)
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
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 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.
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.
** 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.
Comment:
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
Comment:
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Reporting Instructions: The following do not qualify as criteria for
meeting the NHSN definition of superficial SSI

If the superficial incisional infection extends into the fascial and/or
muscle layers, report as a deep incisional SSI only
reportable under this module.

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
Date
Must meet the following Criteria


b.
c.
OREP-Other infection of the male or female reproductive tract
(epididymis, testes, prostate, vagina, ovaries, uterus, or other deep
pelvic tissues, excluding intraabdominal or vaginal cuff infections)
Other infections of the male or female reproductive tract must meet
at least 1 of the following criteria:
2.
3.
Patient has organisms cultured from tissue or fluid
from affected site.
Patient has an abscess or other evidence of
infection of affected site seen during an invasive
procedure or histopathologic examination.
Patient has 2 of the following signs or symptoms:
fever (>38°C), nausea*, vomiting*, pain*,
tenderness*, or dysuria*
AND at least 1 of the following:
a.
organisms cultured from blood
b. Physician diagnosis.
* With no other recognized cause
VCUF-Vaginal cuff infection
Vaginal cuff infections must meet at least 1 of the following criteria:
1.
a.2.
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.
Purulent drainage from a drain that is
placed into the organ/space
Organisms isolated from an
aseptically-obtained 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.
AND Meets at least one criterion for a specific
organ/space infection site listed.
1.
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 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.
Reporting Instructions:
Post-hysterectomy patient has purulent drainage
from the vaginal cuff.
Post-hysterectomy patient has an abscess at the
vaginal cuff.
IAB-Intraabdominal infection, not specified elsewhere including
gallbladder, bile ducts, liver (excluding viral hepatitis), spleen,
pancreas, peritoneum, subphrenic or subdiaphragmatic space, or other
2ntraabdominal tissue or area not specified elsewhere
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.
2. Patient has abscess or other evidence of intraabdominal
infection seen during an invasive procedure or
histopathologic examination.
3.
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, T-tube drain)
organisms seen on Gram’s stain of drainage
or tissue obtained during invasive procedure
or from an aseptically-placed drain
c. Organisms cultured from blood and imaging
test evidence of infection (e.g., abnormal
findings on ultrasound, CT scan, MRI, or
radiolabel scans [gallium, technetium, etc.] or
on abdominal x-ray).
* With no other recognized cause
b.
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3.
Post-hysterectomy patient has pathogens cultured
from fluid or tissue obtained from the vaginal cuff.
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
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 Allergy _______________________________________
Anesthesia ______________________
Incision Closure: Primary/ Non- Primary
Height (cm) _______________
Glucose: 1st Intra op: ___________________________________
Weight (kg)________________
Highest Intraop: _______________________________
Emergency:
Yes
No
Endoscope/Robotic: Yes
Diabetic :
Yes
Trauma Yes
No
No
No
Redose of Antibiotics: _________________________________
Highest 1st day post op: _________________________
Highest 2nd day post op: _________________________
Hair removal __________________________________________
Scrub _______________________________________________
HYST – Abdominal Hysterectomy
Abdominal Hysterectomy: Includes those by laparoscope
68.31, 68.39, 68.41, 68.49, 68.61, 68.69
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.
2/4/14