An SSI Was Reported. Now What? A Step-by-Step Case Review for Surgery Centers
The call usually comes from the surgeon's office: a patient is back with a red, draining incision. Now what? One SSI is a case review. Two or more linked cases is a possible cluster. Either way, the steps are the same, and doing them in order keeps you from missing the one thing that matters.
1. Confirm it is an SSI
Use the CDC NHSN definitions (Patient Safety Component Manual, Chapter 9, January 2026) so every case is judged the same way:
Superficial incisional: skin and subcutaneous tissue only, within 30 days of the procedure.
Deep incisional: fascia and muscle layers.
Organ/space: deeper than the fascia and muscle, such as a joint space or the breast pocket.
Surveillance window: 30 days for most procedures, 90 days for deep and organ/space SSI after higher-risk categories such as hip and knee replacement, breast, hernia, spinal fusion and fracture repair. Superficial SSI is always 30 days.
Get the surgeon's note, culture results, imaging and antibiotic orders. Not every red incision is an SSI. Not every SSI has a culture.
2. Look at the patient
Document the risk factors that were present before surgery, such as diabetes and glucose control, smoking, BMI, skin condition at the site and any known MRSA or MSSA history. Did the patient do the pre-op shower or nasal antisepsis your protocol calls for? This is about understanding the case, not blaming the patient.
3. Look at the process
Walk the case from pre-op to discharge against your own SOPs:
Prophylactic antibiotic: selection and timing documented per your protocol
Hair removal (clippers only, if needed) and skin prep applied and dried per the MIFU
OR traffic, door openings and attire
Normothermia and glucose management per your protocol
Any break in sterile technique noted in the record
4. Look at the loads and the lots
Sterilizer load record for every tray used: physical monitors, chemical indicators and BI results
Any immediate-use steam sterilization (IUSS) and why
Implant and supply lot numbers
Instrument reprocessing per the MIFU, including any loaner trays
OR temperature, humidity and pressure logs for that day
5. Look for other cases
Go back over the last 30 to 90 days. Same surgeon, same procedure, same room, same tray, same organism? If you find two or more that line up, treat it as a possible cluster. Clients, call me, and check your state's reporting requirements.
6. Review it and close the loop
Review the case with your medical director and quality officer, document what you found and what you changed, and bring it to QAPI. CMS requires the ASC infection control program to investigate infections, be an integral part of QAPI, and take immediate corrective and preventive action when needed (42 CFR 416.51). Share the outcome with the surgeon and the staff. They want to know.
Practice tip from Donna: write it down as you go. A case review that lives in someone's head does not exist on survey day. Clients: email me before you close a case and I'll review it with you.
The tool
Clients: the SSI Case Investigation Worksheet in your PreventIQ Library walks you through every step above, from the infection to the patient, the process, the loads and the lots, the check for other cases and the review with your medical director and quality officer. Log in to the client portal to download it.
References
CDC NHSN Patient Safety Component Manual, Chapter 9: Surgical Site Infection (SSI) Event, January 2026. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
CDC NHSN 2026 Surgical Site Infection (SSI) Checklist. https://www.cdc.gov/nhsn/pdfs/checklists/2026-NHSN-Surgical-Site-Infection-SSI-Checklist.pdf
CDC Surgical Site Infection: guidance for healthcare providers. https://www.cdc.gov/infection-control/hcp/surgical-site-infection/index.html
CMS ASC Conditions for Coverage, Infection Control, 42 CFR 416.51. https://www.law.cornell.edu/cfr/text/42/416.51
Training use only. Check current guidance and IFUs. Follow your own SOPs and policies with your medical director and quality officer.