Attachment N: Completion Guide for Surgical Services Clinical Outcomes Data

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment N: Completion Guide for Surgical Services Clinical Outcomes Data

COMPLETION GUIDE FOR CLINICAL OUTCOMES DATA COLLECTION FORM – SURGICAL SERVICES

1. Surgical site infection (SSI) events and causative organisms - monthly

   1. As defined using existing Centers for Disease Control and Prevention (CDC), National Healthcare Safety Network (NHSN) definitions, Chapter 9 of NHSN Patient Safety Component Manual (updated January 2021). Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf

   2. A procedure must meet the NHSN definition of an operative procedure to be included in SSI surveillance. All procedures included in the NHSN monthly surveillance plan are followed for superficial incisional, deep incisional, and organ/space SSI events.

• Count how many confirmed SSI events were caused by each type of SSI organism on the list of organisms on page 3, Attachment K: Clinical Outcomes Data for Surgical Services in each month of the quarter for which you are reporting data.)

• On each row of the table:

  • In the first column, select the appropriate month and year for which you are reporting data from the dropdown menu.

  • In the second column, select the surgical service for which you are reporting data from the dropdown menu.

  • In the third column, select the type of surgical procedure for which you are reporting data from the dropdown menu.

  • In the fourth column, enter the number (count) of SSI cases caused by a given organism.

  • In the fifth column, select the specific organism that was identified to cause the reported SSI cases from the dropdown menu. (See List of Organisms, page 3, Attachment K: Clinical Outcomes Data for Surgical Services)

  • For SSI cases caused by multiple organisms (polymicrobial SSI), count the SSI only once as MRSA or MSSA if either of these grew in the relevant clinical culture(s) to meet the SSI definition. If the SSI was polymicrobial and both MRSA and MSSA grew in the relevant culture(s), count the SSI only once and choose “MRSA” from the organism dropdown list. If the SSI was polymicrobial but neither MRSA nor MSSA grew in the relevant culture(s), count the SSI only once and choose “polymicrobial” from the organism dropdown list.

• Repeat the data entry as above for each of the 3 months in the quarter for which you are reporting data.

2. Number of surgical procedures performed, by type of surgical procedure – monthly

   1. An SSI denominator is defined using existing CDC NHSN definitions, Chapter 4 of NHSN Patient Safety Component Manual (updated January 2021). Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf

   2. An NHSN Operative Procedure is a procedure:

      1. • that is included in the ICD-10-PCS and/or CPT NHSN operative procedure code mapping And

      2. • takes place during an operation where at least one incision (including laparoscopic approach and cranial Burr holes) is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure And

      3. • takes place in an operating room (OR), defined as a patient care area that met the Facilities Guidelines Institute’s (FGI) or American Institute of Architects’ (AIA) criteria for an operating room when it was constructed or renovated. This may include an operating room, C-section room, interventional radiology room, or a cardiac catheterization lab.

   3. Exclusions: Otherwise eligible procedures that are assigned an ASA score of 6 are not eligible for NHSN SSI surveillance.

• Count how many surgical procedures of each type occurred for the participating surgical service in each month of the quarter for which you are reporting data.

• On each row of the table:

  • In the first column, select the appropriate month and year for which you are reporting data from the dropdown menu.

  • In the second column, select the surgical service for which you are reporting data from the dropdown menu.

  • In the third column, select the type of surgical procedure for which you are reporting data from the dropdown menu.

  • In the fourth column, enter the number (count) of surgical procedures performed by the participating surgical service and of the type and time period for which you are reporting data.

• Repeat the data entry as above for each of the 3 months in the quarter for which you are reporting data.