9
Table 3. SSI Prevention Internal Reporting Process and
Outcome Measures
Internal Reporting Process Measure Example: Compliance with Antimicrobial
Prophylaxis Guidelines
Percentage of procedures in which antimicrobial prophylaxis was provided appropriately
= (No. of patients who appropriately received antimicrobial prophylaxis/Total number of
selected operations performed) × 100.
1. Correct antibiotic for specific surgery.
2. Correct antibiotic dose.
3. Administrative start time within 1 hour of incision (2 hours allowed for vancomycin
and fluroquinolones).
4. Discontinuation of agent after skin closure.
Internal Reporting Outcome Measure Example: Surgical Site Infection
Standardized Infection Ratio (SIR)
SIR = Ratio of observed number of SSIs (O)/Predicted number of SSIs (P) for a specific
type of procedure
Table 4. SSI Prevention External Reporting Outcome
Measures
Federal Requirements
a
1. Reported via CDC NHSN in the Centers for Medicare and Medicaid Services
(CMS) Hospital Inpatient Quality Reporting program.
2. Since 2012, SSI data reporting for inpatient abdominal hysterectomy and inpatient
colon procedures has been required.
3. Hospitals in states with a SSI reporting mandate must abide by their state's
requirements, even if they are more extensive than federal requirements.
State Requirements and Collaboratives
1. In states with mandatory SSI reporting requirements, hospitals must collect and
report the data required by the state.
2. Hospitals should check with the state or local health department for requirements.
a
Recommendations and requirements for public reporting provided by HICPAC, the National
Quality Forum, and the CMS.
