Tuesday, 08 December 2015 22:57

Outcome Measures: Surgical Site Infections and CDI

Written by

Outcome measures

What is “quality?” The Centers for Medicare & Medicaid Services (CMS) is trying to define it. In her article in the Nov. 10 edition of VBPmonitor.com, Rachel Mack described in detail what is at stake with the new Medicare requirements for reducing the prevalence of hospital-acquired conditions (HAC). In brief, CMS is putting some teeth into its evaluation of hospitals by instituting an across-the-board reduction in all diagnosis-related group (DRG) reimbursement based primarily on the outcome measures of just three HACs: Central-line associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and colon and abdominal hysterectomy surgical site infections (SSIs). While it seems on face value that it is unfair to evaluate the quality of care for an entire institution based on only three conditions, it also means that targeted analysis of these types of cases by skilled reviewers can ensure that accurate findings are reported to CMS. 

Focus on SSI

Surgical site infections (SSIs) are a new outcomes measure for the  2016 fiscal year, so identifying what “counts” as a reportable infection becomes paramount. First, the procedure itself must be defined as a colon surgery or abdominal hysterectomy; second, it needs to take place during an operation in which at least one incision (including laparoscopic approach) is made through the skin or mucous membrane, or during reoperation via an incision that was left open during a prior operative procedure. Finally, it must take place in an operating room.

Next, the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network (NHSN) define three types of infections:

  • Superficial surgical site
  • Deep incisional infections
  • Organ/space infections, such as peritonitis. 

Only the deep incisional infections and organ/space infections occurring within 30 days of the operation will be considered. There are also exclusions. Diagnosis/treatment of cellulitis (redness, warmth, and/or swelling), by itself, does not meet criterion for incisional SSI, although if the incision is draining, it is not considered a cellulitis. A stitch abscess alone or a localized stab wound would be either a skin or soft tissue (ST) infection, depending on its depth, and is also not reportable for these purposes.

Organ/space infections have these criteria: 

  • Infection is deeper than the fascia/muscle layer;
  • AND purulent drainage from a drain to that space exists, or positive cultures from the area in question, or an abscess or other evidence of infection on exam or imaging test.
  • There is also a requirement that it meet at least one criterion for a specific organ/space infection site; however, since “intra-abdominal, not specified” is one of the options, any organ/space infection resulting from an abdominal hysterectomy or colon surgery would meet this criteria. 

Deep incisional infections have these criteria:

  • It involves the deep tissue layers, such as muscle and fascia

  • Patient has at least one of the following:
    • Purulent drainage from the deep incision;
    • A deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician, or other designee and is culture-positive or not cultured;
      atient has at least one of the following signs or symptoms: fever (>38°C), localized pain, or tenderness. A culture-negative finding does not meet this criterion.
    • An abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam, or imaging test.


Your clinical documentation specialist staff can be instrumental in determining what does or doesn’t make for a SSI that will affect the HAC reduction program. Of particular interest will be clearly differentiating between superficial surgical site infections and the deep incisional infections. The only difference is the tissues involved in the infection. Just as surgeons and other adjunct staff have been asked for years by clinical documentation improvement (CDI) professionals to document the type of tissue in an excisional debridement, they now will need to identify the type of tissue involved in incisional infections. Also note that if an incision is not cultured, it is assumed to be a positive culture, not a negative one. Treatment of the condition is not necessary for the infection to be counted. 

With the greater push for quality outcomes and a very real financial penalty involved for poor performance, it is more crucial than ever that all members of every reimbursement team are on the same page. The need for accuracy in documentation will only increase as quality measures become more important for reimbursement.

More information on this topic, including associated ICD-9 codes, can be found online at http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf. ICD-10 codes will be available in January 2016.  

About the Author

Laurie is a senior healthcare consultant for Panacea Healthcare Solutions, where she performs clinical documentation and quality chart audits that focus on identifying missed opportunities to obtain an accurate and complete record for each patient. Her previous acute-care experience includes emergency department, oncology, and bone marrow transplant. She has been a manager in home care and hospice, and has been the MDS (minimum data set) coordinator for several skilled nursing facilities. She is a registered nurse and a certified clinical documentation specialist (ACDIS).

Contact the Author

This email address is being protected from spambots. You need JavaScript enabled to view it.

Comment on this Article

This email address is being protected from spambots. You need JavaScript enabled to view it.

Last modified on Wednesday, 09 December 2015 05:23

Laurie is a Senior Healthcare Consultant for Panacea Healthcare Solutions where she performs clinical documentation and quality chart audits that focus on identifying missed opportunities to obtain an accurate and complete record for each patient.  Previous acute care experience includes Emergency Department, Oncology, and Bone Marrow transplant.  She has been a manager in Home Care and Hospice, and has been the MDS (Minimum Data Set) Coordinator for several skilled nursing facilities.  She is a Registered Nurse and a Certified Clinical Documentation Specialist (ACDIS).

Latest from Laurie Hilyard, RN, MSN, CCDS