JCAHO defines surgical complications measures

Tracking SSIs within 30 days

The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has developed a surgical complication core measure that includes surgical site infection within 30 days. Specific criteria are summarized as follows:

Performance Measure Name: Surgical site infection (SSI) within 30 days (for selected surgical procedures).

Description: Patients undergoing selected surgical procedures that develop a surgical site infection within 30 days of the procedure.

Focus of Measure: Reducing the incidence of SSIs.

Rationale: SSIs affect 2% to 5% of the 16 million patients undergoing surgical procedures each year in acute care hospitals. There are well-studied risk factors for infections. These infections lead to a significant increase in morbidity and mortality accounting for 24% of all nosocomial infections, second only to urinary tract infection in overall frequency.

Type of measure: Outcome.

Numerator Statement: Patients undergoing selected surgical procedures (utilizing ICD-9-CM codes) who develop SSIs within 30 days after the procedure (incision).

Included Populations: Patients meeting the CDC National Nosocomial Infections Surveil lance definition of SSIs.

Excluded Populations: Patients undergoing procedure (utilizing ICD-9-CM codes) are not included on the list.

Denominator Statement: Patients undergoing selected surgical procedures (utilizing ICD-9-CM codes).

Included Populations: Patients undergoing one of the selected procedures (utilizing ICD-9-CM codes). List of proposed procedures: appendectomy, cardiac surgery (open chest procedures on valves or septum of heart), CABG with both chest and leg incision, CABG with only chest incision, cholecystectomy, colon surgery, open reduction of fracture, vascular surgery, abdominal hysterectomy, mastectomy, hip prosthesis, knee prosthesis, laminectomy, spinal fusion, ventricular shunt, craniotomy, head and neck surgery (entry into oropharynx).