National Casearean Section Surgical Site
Infection Surveillance Form
Draft
*Q1 Hospital Code:
Hospital
Details:
*Q3. Consultant (initials):
*Q2. Patient Number:
Patient Details:
/
*Q4. Date of Birth:
/
/
*Q5. Date of Admission:
/
Height and Weight Measurements:
*Q6. Height:
cm
*Q7. Weight:
Kg
Q9. When was weight taken:
Q8. BMI:
(weeks gestation)
Clinical Details:
Yes
Q10. Previous C/S (s):
No
Q11. Gestation at C/S:
(weeks)
No
Q14. Diabetes:
No
If yes
Yes
Insulin
Gestational
Q15. Was patient on innohep prior to C/S?
D
R
AF
Tablet
Q13. Hours membrane ruptured prior to delivery:
T
Q12. Intact membrane on admssion: Yes
(day)
Yes
No
Procedure and Surgeon Details:
*Q16. Surgery type:
Elective
*Q18. Date of procedure:
Emergency
/
/
*Q17. Operating surgeon (intials):
*Q19. Surgeon grade:
Consultant
SHO
Specialist registrar
Other
Registrar
Q20. If the consultant did not perform procedure was surgeon supervised by consultant?
*Q21. Procedure:
*Q23. Wound class:
Lower uterine segment C/S
*Q22. ASA Class:
Yes
No
1: Normal healthy patient
Upper uterine segment C/S
2: Mild systemic disease
Caesarean hysterectomy
3: Severe systemic disease
Other specified C/S
4: Systemic disease constant threat to life
Unspecified C/S
5: Moribund patient not expected to survive
for 24 hrs
Clean-contaminated
Contaminated
Dirty/Infected
Clean/contaminated: wounds in which the genital or urinary tracts are entered without unusual contamination
Contaminated: operations with major breaks in sterile technique or gross spillage from GI tract and where acute,
non purulent inflmation is encountered.
Dirty/infected: wounds that involve existing clinical infection or perforated visera.
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National Casearean Section Surgical Site
Infection Surveillance Form
Draft
Anaesthesia and Prophylatic Antibiotics:
*Q24. Anaesthesia:
None
*Q25. Prophylactic antibiotics:
General
None
Epidural/spinal
One administration
Two or more administrations
Q27 Antibiotic given:
Cefradine
Erythromycin
*Q26. Timing of antibiotics:
On induction
Within 2 hours prior to incision
Not recorded
More than 2 hours prior to incision
Cefuroxime
At incision
Immediately after cord clamping
Other
Co-Amoxiclav
(please specify other)
Operative Details:
:
*Q28: Time of incision:
Q30. Estimated blood loss:
(mls)
None
Within 24 hrs
*Q31. Part I - Reintervention
time of incision:
please complete if reinterventaion occurred
Outcome:
(If yes, please ensure questions 36 - 42 are completed)
/
Q34 Was the patient re-admitted?
Yes
Q34 Part II-Why was the patient
re-admitted?
Due to SSI
/
*Q35 Part I-Date surveillance discontinued:
/
/
No
Q34 Part I-Date of re-admission
/
30 days in study exceeded
Patient died
Transferred to other hospital
Patient discharged and not
re-amditted within 30 days
Other (please specify):
*Q36. Date of SSI:
****IF PATIENT HAD SSI PLEASE COMPLETE****
/
*Q38. When was the SSI recorded:
*Q39. Infection type:
If SSI go to Q36
Other
*Q35 Part II-Reason surveillance discontinued:
/
SSI Details:
:
*Q33. Date of discharge from hospital:
No
D
R
AF
Yes
After 72 hrs
*Q31. Part II - Reintervention
time of closure:
:
*Q32. Surgical site infection (SSI)?
Within 72 hrs
T
*Q31. Reintervention required:
if yes:
:
*Q29: Time of closure:
/
During admission
Superficial incisional
Q40. Was there a heamatoma?
Q37. Were antibiotics prescribed?
Yes
Post discharge
Deep incisional
During re-admission
Yes
No
Not recorded
Organ/Space
No
*Q41. If organ/space, which site(s) were involved?
Yes
*Q42. Did the patient die?
Arterial or venous infection
Endometritis
Vaginal cuff
Other reproductive
Unrelated to SSI
SSI caused death
Infections of the urinary tract
Intra-abdominal
SSI contributed to death
Relationship unknown
If yes patient died please specify cause:
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No