SSI 3 Percent of Clean Surgery Patients with Surgical Infection by F6NFUxzs

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									                                  SSI 3 - Percentage of Clean Surgery Patients with Surgical Infection
             100%


             90%


             80%


             70%


             60%
Percentage




             50%


             40%


             30%


             20%


             10%


              0%
                    Nov     Feb   May    Aug    Nov     Feb   May    Aug       Nov      Feb    May    Aug    Nov     Feb   May    Aug    Nov
                    2007   2008   2008   2008   2008   2009   2009   2009      2009    2010    2010   2010   2010   2011   2011   2011   2011

                                                                               Month
                                                                            Actual      Goal
SSI 3 - Percentage of Clean Surgery Patients with Surgical Infection - Measurement Worksheet
Prevention of Surgical Site Infections                                                                                                                                                                                                                                       CABG                 Concurrent
                                                                                                                                                                                                                                                                                           Baseline
Intervention    Reducing Surgical Site Infection                                                                                                                                                                                                                                           Early Retrospective
                                                                                                                                                                                                                                                                             Cardiac Surgery
Definition      The rate of infection in patients undergoing clean surgery (NHSN Class 1 or 2 wound class: Appendix C).                                                                                                                                                      Colon SurgeryFull
Goal            Goal may be set by individual organizations/teams however, IHI recommends a reduction of 50%                                                                                                                                                                 C-Section
Data Collection Details                                                                                                                                                                                                                                                      Hip Arthroplasty
Hospital Name                                                                                                          Team #                                                                                                                                                Hysterectomy
Health Region                                                                                                                                                                                                                                                                Knee Arthroplasty
Patient Sample Indicate the surgical procedure you have selected to monitor. Use separate sheets for monitoring individual procedures.                                                                                                                                       Vascular Surgery
                                                                                                                                                                                                                                                                             Other (put procedure in Comment Section)

                                                                  2007                                             2008                                                                          2009                                                                    2010                                                                           2011
                                                                Nov   Dec   Jan   Feb    Mar    Apr     May     Jun     Jul    Aug       Sep   Oct   Nov   Dec   Jan   Feb   Mar   Apr   May   Jun   Jul   Aug   Sep   Oct   Nov   Dec   Jan   Feb   Mar   Apr   May   Jun    Jul   Aug    Sep   Oct    Nov    Dec      Jan   Feb   Mar   Apr   May   Jun   Jul   Aug   Sep   Oct   Nov   Dec
Calculation of Denominator
       Implementation Stage

       Collection Method

  3.1 What is the total number of patients during
      this month who had an inpatient surgical
      procedure of the type indicated above? If
      more than one surgical procedures are
      performed during a single index
      hospitalization include data from the first
      surgical procedure only.
  3.2 What is the total number of patients in # 3.1
      whose age was less than 18 yrs on
      admission to hospital? Exclude from patient list
       for calculating Percentage of “clean” surgery patients
       with surgical infection.

  3.3 Subtract the total of # 3.2 from the total of #
       3.1 and enter here.                              0    0    0    0    0      0      0      0     0     0     0      0       0      0     0      0      0       0     0      0      0      0      0      0      0     0     0       0     0     0      0      0      0     0      0    0      0      0     0       0     0     0      0       0     0      0     0       0      0    0
  3.4 What is the total number of patients with an
       existing infectious process at the same site
       as surgical procedure or surgeries that are
       classified as wound class 1 or 2?
  3.5 Subtract the total of # 3.4 from the total of #
       3.3 and enter here.                              0    0    0    0    0      0      0      0     0     0     0      0       0      0     0      0      0       0     0      0      0      0      0      0      0     0     0       0     0     0      0      0      0     0      0    0      0      0     0       0     0     0      0       0     0      0     0       0      0    0
Calculation of Numerator
  3.6 What is the total number of patients in # 3.5
       (wound classification 1 & 2) who developed
       a post-operative wound
       infection/nosocomial infection within 30
       days of the surgical procedure as defined in
       NHSN (see Appendix C)?
Final Calculation
  3.7 Divide # 3.6 by # 3.5. Multiply by 100.         #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####
       GOAL*:
       *The recommended goal for this measure is to reduce the surgical site infection rate by 50%. Using your baseline data, calculate your target infection rate. For example, if the baseline infection rate is 10% and your goal is to reduce your baseline rate by 50%, your goal would be (10% - (10% x 0.50)) = 5%. Enter your goal rate in each of the monthly cells in row 26 above.




       Comments
Data Year Data Month   Completed By   Email   Phone Number

 2007        Nov
             Dec

 2008        Jan
             Feb
             Mar
             Apr
             May
             Jun
             Jul
             Aug
            Sept
             Oct
             Nov
             Dec

 2009        Jan
             Feb
             Mar
             Apr
             May
             Jun
             Jul
             Aug
            Sept
             Oct
             Nov
             Dec

 2010        Jan
             Feb
             Mar
             Apr
             May
             Jun
       Jul
       Aug
       Sept
       Oct
       Nov
       Dec

2011   Jan
       Feb
       Mar
       Apr
       May
       Jun
       Jul
       Aug
       Sept
       Oct
       Nov
       Dec
Date of Submission (dd/mm/yyyy)

								
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