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## Complete Summary

#### TITLE

Surgical site infection: percentage of superficial surgical site
infections (SSIs) in femoral-popliteal bypass procedures performed,
during the 6 month time period.

#### SOURCE(S)

Australian Council on Healthcare Standards (ACHS). ACHS clinical
indicator users\' manual 2008. ULTIMO NSW: Australian Council on
Healthcare Standards (ACHS); 2007 Dec. 776 p.

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Outcome

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the percentage of superficial incisional
surgical site infections (SSIs) in femoro-popliteal bypass procedures
performed, during the 6 month time period.

The rate of SSIs is expressed per 100 procedures.

#### RATIONALE

The National Strategy to Address Health Care Associated Infections, July
2003 suggests that between 2% to 13% of patients suffer from surgical
site infections (SSIs). The attributable and human costs of SSI are
therefore significant.

The risk of acquiring a SSI is dependent on a number of factors - some
extrinsic e.g., the surgical procedure itself, and some intrinsic
factors, such as the severity of an underlying illness. Surgical
patients who contributed to a clinical indicator should be of similar
risk for infection so that the rate of infection reflects the level of
patient safety in like-type patient groups and infections are not
contributed by a small number of patients with very different risk. The
resultant recording of the clinical indicator rates for SSIs will be
surgical procedure specific and should include revision procedures
(e.g., revision of hip prosthesis).

Health care organisations that perform, routinely, at least 100 surgical
procedures of the same type per year, may evaluate patient safety by
reporting on the frequency of infection and related issues. A higher
volume of procedures will produce a more statistically reliable rate.
Timely investigation of higher than expected rates of infection may
identify issues relating to preventative factors for documentation and
corrective action. For example, errors may have occurred in
administration of the correct type, dose route and timing of
antimicrobial prophylaxis in surgical patients.

#### PRIMARY CLINICAL COMPONENT

Femoro-popliteal bypass procedure; superficial incisional surgical site
infection (SSI)

#### DENOMINATOR DESCRIPTION

Total number of femoro-popliteal bypass procedures\* performed, during
the 6 month time period

\*Refer to the original measure documentation for International
Classification of Diseases, Tenth Revision, Australian Modification
(ICD-10-AM) procedure codes for femoro-popliteal bypass.

#### NUMERATOR DESCRIPTION

Total number of superficial incisional surgical site infections (SSIs)
in femoro-popliteal bypass procedures performed, during the 6 month time
period (see the related \"Numerator Inclusions/Exclusions\" field in the
Complete Summary)

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Use of this measure to improve performance

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

Australian Council on Healthcare Standards (ACHS). Australian clinical
indicator report 1998-2006. Determining the potential to improve quality
of care: 8th edition. ULTIMO NSW: Australian Council on Healthcare
Standards (ACHS); 2007. 564 p.

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement

### Application of Measure in its Current Use

#### CARE SETTING

Hospitals

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Single Health Care Delivery Organizations

#### TARGET POPULATION AGE

Unspecified

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

See the \"Rationale\" field.

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

Unspecified

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Safety

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

Femoro-popliteal bypass procedures performed, during the 6 month time
period

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Total number of femoro-popliteal bypass procedures\* performed, during
the 6 month time period

\*Refer to the original measure documentation for International
Classification of Diseases, Tenth Revision, Australian Modification
(ICD-10-AM) procedure codes for femoro-popliteal bypass.

**Exclusions**\
Unspecified

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Institutionalization\
Therapeutic Intervention

#### DENOMINATOR TIME WINDOW

Time window brackets index event

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Total number of superficial incisional surgical site infections (SSIs)\*
in femoro-popliteal bypass procedures performed, during the 6 month time
period

\*Refer to the original measure documentation for additional information
on SSI and for International Classification of Diseases, Tenth Revision,
Australian Modification (ICD-10-AM) procedure codes.

**Note**: Diagnoses of surgical wound infection that are made following
readmission of a patient within 30 days of surgery are considered to be
\'in-hospital\' diagnoses for the purpose of this indicator and should
be included in the numerator.

**Exclusions**\
Unspecified

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Fixed time period

#### DATA SOURCE

Administrative data\
Medical record

#### LEVEL OF DETERMINATION OF QUALITY

Not Individual Case

#### OUTCOME TYPE

Adverse Outcome

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a lower score

#### ALLOWANCE FOR PATIENT FACTORS

Risk adjustment devised specifically for this measure/condition

#### DESCRIPTION OF ALLOWANCE FOR PATIENT FACTORS

There are many extrinsic and intrinsic risk factors that increase the
likelihood of a surgical patient acquiring an infection, with some
contributing only in presence of others. Risk factors that have been
identified as being important contributors to infection include the
duration of the surgical procedure, the American Society for
Anaesthesiology (ASA) score and degree of contamination of the surgical
site. Large data bases may be able to have the risk factors
statistically adjusted so that the resulting rates reflect a patient
population with similar risk for infection or calculate several rates
for different levels of risk. Most healthcare facilities do not perform
the same type of surgical procedure frequently enough to examine their
rates of infection for several categories of risks. However, it is
recommended that healthcare facilities collect the presence or absence
of several risk factors for each of the surgical patients contributing
to the denominator of their clinical indicator.

The frequency of these risk factors will then be used to describe the
level of risk for the majority of surgical patients in each surveillance
period. This documentation will determine whether risk of infection has
changed. Recommended risk factors include the ASA score, the duration of
procedure, emergency / unplanned and prophylaxis.

#### STANDARD OF COMPARISON

External comparison at a point in time\
External comparison of time trends\
Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

Unspecified

### Identifying Information

#### ORIGINAL TITLE

Indicator area 1: infection surveillance CI 1.11.

#### MEASURE COLLECTION

[Australian Council on Healthcare Standards (ACHS) Equip Clinical
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=1984&doc=11061)

#### MEASURE SET NAME

[Infection Control
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=1984&doc=11835)

#### DEVELOPER

Australian Council on Healthcare Standards

#### FUNDING SOURCE(S)

Funding is direct Australian Council on Healthcare Standards (ACHS)
funding sourced through our membership. ACHS does not receive external
funding from the government or other sources.

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

Our terms of reference dictate the composition of the working parties
that develop our indicators and include the following:

-   Two Clinicians \-- nominated by the relevant specialty
    college/association/society, one nominated to be the chair of the
    working party

-   Private Hospital Representative \-- nominated by the Australian
    Private Hospital Association

-   Consumer Representative \-- nominated by the Consumer Health Forum
    of Australia

-   Coding Representative \-- nominated by the National Centre for
    Clinical classification on Health

-   Quality Health New Zealand, nominated by QHNZ (if applicable)

-   Epidemiological/Clinical Research Representative, Director of Health
    Services Research Group, University of Newcastle

-   Australian Council on Healthcare Standards (ACHS) Representatives
    \-- Clinical Director, Coordinator, Administrative Assistant

-   Other Expert Stakeholders, as required

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

None

#### ADAPTATION

These indicators have been replicated with permission, from the New
South Wales (NSW) Health Department Infection Control Program Quality
Monitoring Indicators Version 2.

The Australian Council on Healthcare Standards (ACHS) Infection Control
Indicators were developed in accordance with the standard set of
definitions published by the Australian Council for Safety and Quality
in Health Care\'s, Health Care Associated Infections Advisory Committee
(HCAIAC) and Surveillance Working Party. The definitions were originally
developed by the National Advisory Board of the Australian Infection
Control Association based on the National Nosocomial Infections
Surveillance Systems, the Nosocomial Infection National Surveillance
System and from the Public Health Laboratory Service of the UK (PHLS).

#### RELEASE DATE

2002 Jan

#### REVISION DATE

2007 Dec

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

Australian Council on Healthcare Standards (ACHS). ACHS clinical
indicator users\' manual 2008. ULTIMO NSW: Australian Council on
Healthcare Standards (ACHS); 2007 Dec. 776 p.

#### MEASURE AVAILABILITY

The individual measure, \"Indicator Area 1: Infection Surveillance CI
1.11,\" is published in \"ACHS Clinical Indicator Users\' Manual 2008.\"

For more information contact, the Australian Council on Healthcare
Standards (ACHS), 5 Macarthur Street, ULTIMO NSW 2007; Phone: (02) 9281
9955; Fax: (02) 9211 9633; E-mail: <pos@achs.org.au>; Web site:
[www.achs.org.au](http://www.achs.org.au/).

#### COMPANION DOCUMENTS

The following is available:

-   Australian Council on Healthcare Standards (ACHS). Australian
    clinical indicator report 1998-2006. Determining the potential to
    improve quality of care: 8th edition. ULTIMO NSW: Australian Council
    on Healthcare Standards (ACHS); 2007. 564 p. This document is
    available in Portable Document Format (PDF) from the [Australian
    Council on Healthcare Standards (ACHS) Web
    site](http://www.achs.org.au/pdf/Australasian_CIR_8th_Edition.pdf).

#### NQMC STATUS

This NQMC summary was completed by ECRI Institute on September 19, 2008.

#### COPYRIGHT STATEMENT

This NQMC summary is based on the original measure, which is subject to
the measure developer\'s copyright restrictions. This work is copyright.
Apart from any use as permitted under the Copyright Act 1968, no part
may be reproduced by any process without written permission from The
Australian Council on Healthcare Standards (ACHS).

### Disclaimer

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/10/2008