Measure 357 – Surgical Site Infection

Audit Criteria

When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 357 requires documentation that a patient had a surgical site infection (SSI).

 

NOTE: This is an inverse measure, the lower the percentage of patients with a surgical site infection, the better quality of care provided.

 

NOTE: This measure should only be reported for surgical procedures performed by November 30.

 

This documentation may be found in the patient’s medical record. The relevant document should be made available to the auditor for the patient requested.

 

What constitutes a surgical site infection?

The measure steward has provided information on the surgical site infection types that should be reported for this measure and their characteristics. In most cases, if a surgeon or attending physician has diagnosed the patient with a surgical site infection, this qualifies for the performance met numerator option and you should ensure that this is noted in the patient’s history:

 

Infection Type

Characteristics

Superficial Incisional SSI

·         Only involves skin or subcutaneous tissue of the incision and includes one of the following:

o   Purulent drainage, with or without laboratory confirmation, from the superficial incision.

o   Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.

o   Pain or tenderness, localized swelling, redness, or heat AND superficial incision is deliberately opened by the surgeon, unless incision is culture negative.

o   Diagnosis of superficial incisional SSI by the surgeon or attending physician.

Deep Incisional SSI

·         Infection appears to be related to the operation and infection involves deep soft tissues of the incision and at least one of the following:

o   Purulent drainage from the deep incision but not from the organ/space component of the surgical site.

o   A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (> 38 C), localized pain, or tenderness, unless site is culture-negative.

o   An abscess or other evidence of infection involving the deep incision is found on direct examination, during re-operation, or by histopathologic or radiologic examination.

o   Diagnosis of a deep incision SSI by a surgeon or attending physician.

Organ/Space SSI

·         Infection appears to be related to the operation and the infection involves any part of the anatomy other than the incision, which was opened or manipulated during an operation and at least one of the following:

o   Purulent drainage from a drain that is place through a stab wound into the organ/space.

o   Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space.

o   An abscess or other evidence of infection involving the organ/space that is found on direct examination, during re-operation, or by histopathologic or radiologic examination.

o   Diagnosis of an organ/space SSI by a surgeon or attending physician.