Prevent surgical site infections by documentation

May 9, 2024

1. For “cellulitis” or “stitch abscess,” please select impression/diagnosis as “cellulitis: or “stitch abscess.” Do not select “postop infection” or “wound infection” or “surgical site infection”.

Rationale: Per NHSN, Diagnosis/treatment of cellulitis (redness/warmth/swelling), by itself, does not meet superficial incisional SSI criterion. Also, a stitch abscess alone (minimal inflammation and discharge confined to the points of suture penetration) is not considered a surgical site infection. However, a diagnosis of “surgical site infection” or “postop infection” or “wound infection” qualifies for a superficial surgical site infection.

2. PATOS = Infection Present at the Time of Surgery. Document in the narrative portion of the operative note and NOT on routine headings (pre/post op diagnoses, ‘indication for surgery’, and other headings routinely included in an operative note are not eligible with answering PATOS).

Examples of verbiage that is considered evidence of infection (PATOS) include but are not limited to:

  • abscess, infection
  • purulence/pus
  • phlegmon
  • osteomyelitis
  • feculent peritonitis
  • A ruptured/perforated appendix is evidence of infection at the organ/space level

Note: Colon perforation, contamination, necrosis, gangrene, fecal spillage, nicked bowel during procedure, murky fluid, or documentation of inflammation are NOT considered evidence of infection!

3. For a clear drainage from superficial incision, please ensure if culture is absolutely necessary since normal microflora from culture is considered positive for surgical site infection.

Rationale: Per NHSN, organism(s) identified from an aseptically obtained specimen from the superficial incision qualifies for a surgical site infection.

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