SURGICAL SITE INFECTION (SSI) WORKSHEET NHSN #______

PATIENT NAME: / Unit / ID# / HA SSI: YES NO
MC#
PROC: / AGE:
DOB: / INITIAL ADMIT/D/C: / READMIT:
M F / DX: / DX:
DIABETES: Y N / HT: / WT / PRIMARY CLOSURE: Y N
PROC DATE: / WND CLASS: (1) CLEAN (2) CLEAN/CONTAM (3) CONTAM (4) DIRTY
SURGEON: / PST/PFT: / ASA: 1 2 3 4 5 E / RISK: 0 1 2 3 / IMPLANT: Y N
T Time:
CULTURES / DATE / #1 / #2 / #3 / #4
SITE
ORGANISM(S)
EVENT: Superficial Incisional Primary (SIP)* Superficial Incisional Secondary (SIS)**  Deep Incisional Primary (DIP)*  Deep Incisional Secondary (DIS)**  ORGAN SPACE
SUPERFICIAL INCISIONAL: / DEEP INCISIONAL SSI: / ORGAN/SPACE SSI:
□Infection occurs within 30 days after the operative procedure AND
□Infection involves only skin or subcutaneous tissue of incision AND
□At least one of the following: / □Infection occurs within ***30/90 days after the operationand infection(s) appears to be related to the operation AND
□Infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision AND
□At least one of the following: / □Infection occurs within *30/90 days after the operation, and the infection appears to be related to the operative procedure AND
□Infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during operation AND
□At least one of the following:
DATE / DATE / DATE
  1. Purulent drainage from the superficial incision.
/
  1. Purulent drainage from the deep incision but not from the organ/space component of the surgical site
/
  1. Purulent drainage from a drain that is placed through a stab wound into the organ/space

  1. Organisms isolated from an aseptically obtained culture from the superficial incision or subcutaneous tissue.
/
  1. A deep incision that spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured AND has at least one s/s: fever (>38°C or 100.4 F); or localized pain/or tenderness. Culture-negative does not meet this criterion
/
  1. Organism(s) isolated from an aseptically obtained culture of fluid or tissue in the organ /space

  1. Superficial incision is deliberately opened by surgeon/designee and is culture positive or not cultured andhas atleast one of the following signs/symptoms of infection: pain/tenderness, localized swelling, redness or heat. Culture-negative does not meet this criterion..
/
  1. An abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologicexam or imaging test.
/
  1. An abscess or other evidence of infection involving the organ/space on direct examination during reoperation, or by histopathologic or readiologic examination

  1. Diagnosis of superficial incision SSI by the surgeon or attending physician

*Primary: incision in a patient that has had an operation with one incisionRevised: April 2015

**Secondary: incision in a patient that has had an operation with more than one incision (e.g. donor site)

  • Report infection that involves both superficial and deep incision sites as deep incisional SSI.
  • “Cellulitis”, by itself, does not meet the criteria for Superficial Incisional SSI.
  • Report organ/space SSI that drains through the incision as a deep incisional SSI.
  • Return to OR within 24 hours: the T-times are addedto the original surgery
  • *30/90 – day Surveillance:

a)30-day: AAA, AMP, APPY, AVSD, BILI, CEA, CHOL, COLO, CSEC, GAST, HTP, HYST, KTP, LAM, LTP, NECK, NEPH, OVRY, PRST, REC, SB, SPLE, THOR, THYR, VHYS, XLAP

b)90-day: BRST, CARD, CBGB, CBGC, CRAN, FUSN, FX, HER, HPRO, KPRO, PACE, PVBY, RFUSN, VSHN.