1 SUPERFICIAL SURGICAL-SITE INFECTIONS COLORECTAL

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1 1 SUPERFICIAL SURGICAL-SITE INFECTIONS COLORECTAL Pathway 1 COLORECTAL * Diverting Stoma * No diversion For 2 weeks 1. CBC SUPER- FICIAL INCISIONAL + Wound vacuum Discharge to Home Out patient follow up hours + Wound opening + Wound packing Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing

2 WORKSHEET 1.1: SUPERFICIAL COLORECTAL 2 Scenario: A 32-year-old woman presented with chronic abdominal pain. She was previously found to have pelvic floor dysfunction. Pelvic floor retraining was tried with out success. Hand assisted laparoscopic subtotal colectomy with ileorectostomy was performed. Patient presents with redness around the surgical site incision. Patient is started on oral antibiotics and symptoms improve. Discharged home with instructions to complete oral antibiotics and monitor site for infection. COLORECTAL For 2 weeks * Diverting Stoma * No diversion 1. CBC SUPER- FICIAL INCISIONAL + Wound vacuum Discharge to Home Out patient follow up hours + Wound opening + Wound packing Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Complete Blood Count once a day x 4 days Blood Draw x 4 days : One of the following is prescribed x days; y; 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab CBC (CPT 85027) Blood Draw (CPT 36415) Levofloxacin tab Augmentin tab

3 WORKSHEET 1.2: SUPERFICIAL COLORECTAL 3 Scenario: A 62-year-old woman with iron deficiency anemia underwent colonoscopy which showed a large polyp not amenable to removal. Biopsy showed fragments of tubulovillous adenoma and low grade dysplasia. Laparoscopic assisted right hemicolectomy was performed. Patient presents with redness around the surgical site incision, elevated WBC count, and temperature of Pt receives four doses of IV antibiotic and redness decreases. Patient is switched to oral antibiotics and discharged home with instructions for follow-up and for completion peto of antibiotics. tbotcs COLORECTAL For 2 weeks * Diverting Stoma * No diversion 1. CBC SUPER- FICIAL INCISIONAL + Wound vacuum Discharge to Home Out patient follow up hours + Wound opening + Wound packing Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Complete Blood Count once a day x 4 days Blood Draw x 4 days : One of the following is prescribed x 4 days: 1. Levofloxacin IV 2. Cefazolin IV : One of the following is prescribed x 10 days; 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab CBC (CPT 85027) Blood Draw (CPT 36415) Levofloxacin IV Cefazolin IV Levofloxacin tab Augmentin tab

4 WORKSHEET 1.3: SUPERFICIAL COLORECTAL 4 Scenario: A 56-year-old woman with ten year history of Crohn's disease presented with abdominal discomfort, bloating, nausea and vomiting. She was on Remicade and 6-mercaptopurine with no relief of symptoms. CT abdomen showed evidence of stricturing Crohn's disease. Hand assisted laparoscopic small bowel resection with stricturoplasties were performed. Patient presents with slight dehiscense of surgical incision. Patent is strated on and wound vac x 4 days. Wound heals well and patient is switched to oral antibiotics and eventually discharged dsc agedwith follow-up o by home health nurse. COLORECTAL For 2 weeks * Diverting Stoma * No diversion 1. CBC SUPER- FICIAL INCISIONAL + Wound vacuum Discharge to Home Out patient follow up hours Daily Wound Dressing + Wound opening + Wound packing Visiting Nurse Home visits + Wound dressing / Home Wound Vac Complete Blood Count once a day x 4 days Blood Draw x 4 days : One of the following is prescribed x 4 days: 1. Levofloxacin IV 2. Cefazolin IV Wound vacuum x 4 days (Assuming patient required Wound Vacuum only in hospital) - There is no billing event for daily wound dressing Nursing time. : One of the following is prescribed x 10 days; 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab CBC (CPT 85027) Blood Draw (CPT 36415) Levofloxacin IV Cefazolin IV Wound Vacuum Daily wound dressing: not billed Levofloxacin tab Augmentin tab

5 WORKSHEET 1.4: SUPERFICIAL COLORECTAL 5 A 56 year old female presented with low pelvic pain and urinary tract symptoms. CT abdomen and pelvis revealed an abscess in the pouch of Douglas with fistula from the abscess to the sigmoid colon, due to diverticulitis. Abdominal exploration with drainage of pelvic abscess and sigmoid resection was performed. Patient presents with redness and edema around the surgical site incision. Physician reopens incision and packs. Daily dressing changes are prescribed as well as. Site heals well. Patient changed to oral antibiotics and discharged home with follow-up o from visiting nurse. COLORECTAL For 2 weeks * Diverting Stoma * No diversion 1. WBC SUPER- FICIAL INCISIONAL + Wound vacuum Discharge to Home Out patient follow up hours + Wound opening + Wound packing Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Complete Blood Count once a day x 4 days Blood Draw x 4 days : One of the following is prescribed x 4 days: 1. Levofloxacin IV 2. Cefazolin IV There is no billing event for daily wound dressing Nursing time. : One of the following is prescribed x 10 days; y; 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab CBC (CPT 85027) Blood Draw (CPT 36415) Levofloxacin IV Cefazolin IV Wound opening and packing: not billed when done on the floors Levofloxacin tab Augmentin tab

6 6 DEEP INCISIONAL SURGICAL-SITE INFECTIONS COLORECTAL Pathway 2 COLORECTAL + Wound opening + Wound packing * Diverting Stoma * No diversion Discharege Daily Wound Dressing Oral Antibiotics / 1 week 1. CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS hours DEEP INCISIONAL + Wound opening + Wound vacuum Daily Wound Dressing + Wound debridement in Operative room Discharge to Home Out patient follow up Visiting Nurse Home visits + Wound dressing / Home Wound Vac

7 WORKSHEET 2.1: DEEP INCISIONAL COLORECTAL 7 Scenario: A 35-year-old male with medically refractory Crohn disease presented with small bowel obstruction. He had h/o multiple hospitalizations and small bowel obstruction and multiple stricturoplasties. He is currently on high dose steroids and 6-mercaptopurine. Exploratory laparotomy, resection of ileocolic anastomosis and stricturoplasty were performed. Due to complications, patient stays 4 additional days. On the fourth day post-op, swelling, drainage, and erythema noted at incision. CT scan shows abscess in fascia. Wound is reopened and packed and daily dressing changes with are ordered. ed Wound responds well to treatment e t and culture and sensitivity s ty confirms treatment selection. Patient switched to oral antibiotics and discharged home with home health follow up for wound care. COLORECTAL + Wound opening + Wound packing * Diverting Stoma * No diversion Discharege Daily Wound Dressing Oral Antibiotics / 1 week 1. CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS hours DEEP INCISIONAL + Wound opening + Wound vacuum Daily Wound Dressing + Wound debridement in Operative room Discharge to Home Out patient follow up Visiting Nurse Home visits + Wound dressing / Home Wound Vac CT Scan Abdomen w/ contrast CT Scan Pelvis w/ contrast Complete Blood Count once a day x 8 days Blood Draw x 8+1 days General Bacterial Culture Antibiotic susceptibility : One of the following is prescribed x 8 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV. There is no billing event reported for daily wound dressing. (also for wound opening and packing on the floors) x 7 days 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab Floor Care Room Costs (Not billed with CPT4 codes) x 4 days extra stay for Deep Incisional. CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) CT Scan Abdomen w/contrast (CPT 74160) CT Scan Pelvis w/contrast (CPT 72193) Levofloxacin IV Cefazolin IV Daily wound dressing: not billed Levofloxacin tab Augmentin tab Semiprivate Room Private Room

8 WORKSHEET 2.2: DEEP INCISIONAL COLORECTAL 8 Scenario: A 50-year-old male presented for elective resection of the sigmoid colon after two document episodes of diverticulitis. One of the episode required hospitalization with. Colonoscopy did not reveal any other pathology except for edematous sigmoid colon. CT abdomen & pelvis showed marked thickening of the sigmoid colon and inflammatory stranding in the pericolonic fat. Laparoscopic converted to open, sigmoid Colectomy was performed. Six days post-op, wound begins to leak foul-smelling discharge. Patient temperature is 101 and incision cso ste site is warm and red. CT shows sabscessa and wound dcutue culture is spost positive for infection ecto in fascia. asca Incision cso is reopened edand patient t is placed on wound vac x 8 days and. After 8 days, site healing well with good granulation tissue. Patient is discharged to home health with wound vac and oral antibiotics. COLORECTAL + Wound opening + Wound packing * Diverting Stoma * No diversion Discharege Daily Wound Dressing Oral Antibiotics / 1 week 1. CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS hours DEEP INCISIONAL + Wound opening + Wound vacuum Daily Wound Dressing + Wound debridement in Operative room Discharge to Home Out patient follow up Visiting Nurse Home visits + Wound dressing / Home Wound Vac CT Scan Abdomen w/ contrast CT Scan Pelvis w/ contrast Complete Blood Count once a day x 8 days Blood Draw x 8+1 days General Bacterial Culture Antibiotic susceptibility : One of the following is prescribed x 8 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV. There is no billing event reported for daily wound dressing. Wound vacuum x 8 days x 7 days 1. Cephalexin cap; 2. Levofloxacin tab; 3. Augmentin Tab. Floor Care Room Costs (Not billed with CPT4 codes) x 4 days extra stay for Deep Incisional. CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) CT Scan Abdomen w/contrast (CPT 74160) CT Scan Pelvis w/contrast (CPT 72193) Levofloxacin IV Cefazolin IV Wound Vacuum Daily wound dressing: not billed Levofloxacin tab Augmentin tab Semiprivate Room Private Room

9 WORKSHEET 2.3: DEEP INCISIONAL COLORECTAL 9 Scenario: A 57-year-old male comes with h/o right upper quadrant abdominal pain for 5 months accompanied with decreased appetite and weight loss. Colonoscopy showed an annular lesion in the ascending colon which is biopsy proven adenocarcinoma. The metastatic work up was negative. Laparoscopic Right hemicolectomy was performed. Four days post-op, incision site is very red and edematous. Patient temperature is and patient complains of increased pain to site. CT shows deep incisional infection. Wound drainage culture positive for bacterial infection. Patient t started ted on and returned ed to OR for surgical wound debridement e under spinal anesthesia. a Site heals well with daily wound management by nursing. Patient changes to po antibiotics and is discharged home with home health for ongoing wound management. COLORECTAL + Wound opening + Wound packing * Diverting Stoma * No diversion Discharege Daily Wound Dressing Oral Antibiotics / 1 week 1. CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS hours DEEP INCISIONAL + Wound opening + Wound vacuum Daily Wound Dressing + Wound debridement in Operative room Discharge to Home Out patient follow up Visiting Nurse Home visits + Wound dressing / Home Wound Vac CT Scan Abdomen w/ contrast CT Scan Pelvis w/ contrast Complete Blood Count once a day x 8 days Blood Draw x 8+1 days General Bacterial Culture Antibiotic susceptibility : One of the following is prescribed x 8 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV. Wound debridement in the operative room is not coded with CPT Codes x 7 days 1. Cephalexin cap; 2. Levofloxacin tab; 3. Augmentin Tab. Floor Care Room Costs (Not billed with CPT4 codes) x 4 days extra stay for Deep Incisional. CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) CT Scan Abdomen w/contrast (CPT 74160) CT Scan Pelvis w/contrast (CPT 72193) Levofloxacin IV Cefazolin IV OR PACU (IP 10230) AlloDerm graft (IP ) Spinal Anesthesia (IP 21885) Anesthesia supplies Levofloxacin tab Augmentin tab Semiprivate Room Private Room

10 10 ORGAN/SPACE SURGICAL-SITE INFECTIONS COLORECTAL Pathway 3 COLORECTAL Conservative management * Diverting Stoma * No diversion 1. CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. Blood Culture 6. Chest X-Ray 7. URINE Analysis Discharege hours ORGAN / SPACE + CT guided + Operative room Repeat CT every 5-7 days ICU Care Floor Care Incubation for hours with multiple CXR, ABG, WBC, Electrolytes, Creatinine, etc. Out patient follow up 2 week 2 week Oral antibiotics Visiting Nurse Home visits + Wound dressing / Home Wound Vac

11 WORKSHEET 3.1: ORGAN/SPACE COLORECTAL 11 Scenario: A 75 year old gentleman presented with recent changes in his bowel habits including bleeding per rectum and was recommended a screening colonoscopy. Colonoscopy showed pan diverticulosis and ulcerative lesion 10 cm from the anal verge. Biopsy proved it to be an high grade dysplasia. He had h/o prostate cancer. Proctectomy was performed. Five days post-op, CT ordered and physician diagnoses organ space infection. Physician orders transfer to ICU, ICU panel of tests, and. CT scan repeated and patient shows healing. Transferred to floor and infection continues to decrease. ease Patient t discharged home with visiting nurse management age e of incision site and oral antibiotics. botcs COLORECTAL Conservative management * Diverting Stoma * No diversion 1. CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. Blood Culture 6. Chest X-Ray 7. URINE Analysis Discharege hours ORGAN / SPACE + CT guided + Operative room Repeat CT every 5-7 days ICU Care Floor Care Incubation for hours with multiple CXR, ABG, WBC, Electrolytes, Creatinine, etc. Out patient follow up 2 week 2 week Oral antibiotics Visiting Nurse Home visits + Wound dressing / Home Wound Vac CT Scan Abdomen w/ contrast CT Scan Pelvis w/ contrast Complete Blood Count once a day x 8 days Blood Draw x 8 days General Bacterial Culture Antibiotic susceptibility : One of the following is prescribed x 8 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV 3. Piperacillin/Tazobactam IV 4. Metronidazole Premix 5. Vancomycin IV x 7 days 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab 4. Metronidazole tab ICU Care x 2 days Floor Care Room Costs x 4 days CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) CT Scan Abdomen w/contrast (CPT 74160) CT Scan Pelvis w/contrast (CPT 72193) Chest X-Ray PA & lateral (CPT 71020) X-Ray Abdomen (CPT 74000) Urinalysis, routine (CPT 81001) Levofloxacin IV Cefazolin IV Piperacillin/Tazobactam IV Metronidazole Premix Vancomycin IV Levofloxacin tab Augmentin tab Metronidazole tab Parenteral nutrition Semiprivate Room Private Room Semiprivate Room Private Room ICU Room Other ICU Care (18 other tests)

12 WORKSHEET 3.2: ORGAN/SPACE COLORECTAL 12 Scenario: A 38 year old female presented with medically refractory ulcerative colitis. She was on steroids and infliximab prior to the presentation. She had past history of laparoscopic hysterectomy and C- section. Hand assisted laparoscopic total proctocolectomy with ileal pouch anal anastomosis and diverting ileostomy was performed. Four days post-op, patient complains of severe pain to surgical site. CT shows organ space infection. Physician uses CT guided drainage to treat, followed by course of and ICU admission. Repeat CTs show improvement and patient t is transferred ed to MedSurg after 48 hours. Several e days later, patient t is discharged home with wound care and ongoing g antibiotics. COLORECTAL Conservative management * Diverting Stoma * No diversion 1. CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. Blood Culture 6. Chest X-Ray 7. URINE Analysis Discharege hours ORGAN / SPACE + CT guided + Operative room Repeat CT every 5-7 days ICU Care Floor Care CT Sinogram every 7-10 days Incubation for hours with multiple CXR, ABG, WBC, Electrolytes, Creatinine, etc. Out patient follow up 2 week 2 week Oral antibiotics Visiting Nurse Home visits + Wound dressing / Home Wound Vac CT Scan Abdomen w/ contrast CT Scan Pelvis w/ contrast Complete Blood Count once a day x 8 days Blood Draw x 8 days General Bacterial Culture Antibiotic susceptibility : One of the following is prescribed x 8 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV 3. Piperacillin/Tazobactam IV 4. Metronidazole Premix 5. Vancomycin IV x 7 days 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab 4. Metronidazole tab CT Guided CT Sinogram x 2 Other Care assoc. with CT Sinogram ICU Care x 2 days Floor Care Room Costs x 4 days CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) CT Scan Abdomen w/contrast (CPT 74160) CT Scan Pelvis w/contrast (CPT 72193) Chest X-Ray PA & lateral (CPT 71020) X-Ray Abdomen (CPT 74000) Urinalysis, routine (CPT 81001) Levofloxacin IV Cefazolin IV Piperacillin/Tazobactam IV Metronidazole Premix Vancomycin IV : 5 items Microbiology: 4 items CT Sinogram + 2 items Levofloxacin tab Augmentin tab Metronidazole tab Parenteral nutrition Semiprivate Room Private Room ICU Room Other ICU Care (18 other tests)

13 WORKSHEET 3.3: ORGAN/SPACE COLORECTAL 13 Scenario: A 23 year old male with h/o familial adenomatous polyposis comes presents with anal stricture. He had total proctocolectomy with ileal pouch anal anastomosis. He had anal dilatation with diverting ileostomy for anal stricture. Abdominal exploration with ileal J-pouch excision and end ileostomy was performed. Patient develops signs of organ space 4 days postoperatively. CT and microbiology confirm. Patient returns to OR for incision and drainage of lesion under anesthesia. Patient is admitted to the ICU with and close monitoring. Infection responds to treatment e t and patient t is eventually e discharged home. COLORECTAL Conservative management * Diverting Stoma * No diversion 1. CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. Blood Culture 6. Chest X-Ray 7. URINE Analysis Discharege hours ORGAN / SPACE + CT guided + Operative room Repeat CT every 5-7 days ICU Care Floor Care CT Sinogram every 7-10 days Incubation for hours with multiple CXR, ABG, WBC, Electrolytes, Creatinine, etc. Out patient follow up 2 week 2 week Oral antibiotics Visiting Nurse Home visits + Wound dressing / Home Wound Vac CT Scan Abdomen w/ contrast CT Scan Pelvis w/ contrast Complete Blood Count once a day x 8 days Blood Draw x 8 days General Bacterial Culture Antibiotic susceptibility : One of the following is prescribed x 8 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV 3. Piperacillin/Tazobactam IV 4. Metronidazole Premix 5. Vancomycin IV x 7 days 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab 4. Metronidazole tab CT Guided CT Sinogram x 2 Other Care assoc. with CT Sinogram ICU Care x 2 days Floor Care Room Costs x 4 days CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) CT Scan Abdomen w/contrast (CPT 74160) CT Scan Pelvis w/contrast (CPT 72193) Chest X-Ray PA & lateral (CPT 71020) X-Ray Abdomen (CPT 74000) Urinalysis, routine (CPT 81001) Levofloxacin IV Cefazolin IV Piperacillin/Tazobactam IV Metronidazole Premix Vancomycin IV : 5 items Microbiology: 4 items CT Sinogram + 2 items Levofloxacin tab Augmentin tab Metronidazole tab Parenteral nutrition OR PACU (IP 10230) Semiprivate Room Private Room ICU Room Other ICU Care (18 other tests) Spinal Anesthesia (IP 21885) Anesthesia supplies (IP 90889)

14 1 SUPERFICIAL SURGICAL-SITE INFECTIONS MEDIASTINAL (, Inpatient, Limited Deep) Pathway 1 Additional weekly visits x 3-4 weeks For 10 days-2 weeks CT Surgery Isolated CABG Diagnosis? 1-10 days 1. WBC COUNT 2. Blood cultures 3. Wound Culture & Sensitivity hours SUPERFICIAL INCISIONAL If Open wound Discharge to Home Visiting Nurse Home visits + Wound dressing + Home Wound Vacuum Daily Wound Dressing Dressing change Nugauze/Saline Wet to dry, Aqua silver and Meplex Border Weekly follow-up

15 WORKSHEET 1.1: Superficial Mediastinal (, Inpatient, Limited Deep) 2 Scenario: 50-year-old male underwent CABG. Patient complains of chest pains and has fever of 99.5 F; wound site is red. Doctor orders CBC and blood cultures x 2 with sensitivity. Wound culture positive. Oral antibiotic for 10 days. Repeat CBC in 48 hours. Issue resolves. CT Surgery Isolated CABG Diagnosis? For 10 days-2 weeks 1-10 days 1. WBC COUNT 2. Blood cultures for fever SUPERFICIAL INCISIONAL Discharge to Home hours If Open wound Visiting Nurse Home visits + Wound dressing + Home Wound Vacuum Daily Wound Dressing Dressing change Nugauze/Saline Wet to dry, Aqua silver and Meplex Border Weekly follow-up x days: 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab Complete Blood Count x 2 Blood Culture x 2 Blood Draw x 2 Culture and Sensitivity x 1 Room Costs x 2 days CBC (CPT 85027) Blood Culture (CPT 87040) Blood Draw (CPT 36415) Culture and Sensitivity (87070) Semiprivate Room Private Room Levofloxacin tab Augmentin tab

16 WORKSHEET 1.2: Superficial Mediastinal (, Inpatient, Limited Deep) 3 Scenario: 62-year-old female underwent CABG. Patient complains of chest pains and has fever of 99.5 F; wound site is red. Doctor orders CBC and blood cultures x 2 with sensitivity. Lab results show positive blood culture, and patient is put on for 2 days. Change to oral antibiotics for days. Issue resolves. CT Surgery Isolated CABG Diagnosis? For 10 days-2 weeks 1-10 days 1. WBC COUNT 2. Blood cultures for fever SUPERFICIAL INCISIONAL Discharge to Home hours If Open wound Visiting Nurse Home visits + Wound dressing + Home Wound Vacuum Daily Wound Dressing Dressing change Nugauze/Saline Wet to dry, Aqua silver and Meplex Border Weekly follow-up Complete Blood Count x 3 Blood Culture x 2 Blood Draw x 3 Wound Culture and Sensitivity x 1 : One of the following is prescribed x 2 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV x days: 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab Room Costs x 2 days CBC (CPT 85027) Blood Culture (CPT 87040) Blood Draw (CPT 36415) Culture and Sensitivity (87070) Levofloxacin IV Cefazolin IV Levofloxacin tab Augmentin tab Semiprivate Room Private Room

17 WORKSHEET 1.3: Superficial Mediastinal (, Inpatient, Limited Deep) 4 Scenario: 70-year-old male underwent isolated CABG. 2 Days post-op, complains of pain and redness at surgical site and purulent drainage; the site is not well approximated and patient with fever of 100 F. Physician orders CBC, blood culture, wound culture w/ sensitivity. Physician opens, irrigates, and drains wound, and orders x 3 days. Changed to oral antibiotics after patient improves (10-14 days). CT Surgery Isolated CABG Diagnosis For days 1-10 days 1. WBC COUNT 2. Blood cultures for fever SUPERFICIAL INCISIONAL Discharge to Home hours If Open wound Visiting Nurse Home visits + Wound dressing + Home Wound Vacuum Daily Wound Dressing Dressing change Nugauze/Saline Wet to dry, Aqua silver and Meplex Border Weekly follow-up : One of the following is prescribed x 3 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV Complete Blood Count x 3 Blood Culture x 2 Blood Draw x 3 Wound Culture and Sensitivity x 1 Room Costs x 2 days One of the following is prescribed x days: 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab CBC (CPT 85027) Blood Culture (CPT 87040) Blood Draw (CPT 36415) Culture and Sensitivity (87070) Wound Dressing Levofloxacin IV Cefazolin IV Semiprivate Room Private Room Levofloxacin tab Augmentin tab

18 5 DEEP INCISIONAL SURGICAL-SITE INFECTION MEDIASTINAL Pathway 2 Post-op Hospital Length of stay (days) Adds 7-10 days + Wound opening + Wound Packing CT Surgery Isolated CABG 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. ID Consult hours DEEP INCISIONAL + Wound opening + Wound vacuum dressing (x 3 days) Repeat CT Scan + Wound debridement in operating room + Wound vac x 3 days + Daily wound dressing x 2 weeks Possible IV abx Discharge to Home Visiting Nurse Home visits + Wound dressing + Home Wound Vacuum follow-up

19 WORKSHEET 2.1: Deep Incisional Mediastinal 6 Scenario: 63-year-old female, 2 days post-op CABG, develops fever of F, pain and redness around surgical site. Doctor orders CBC, blood cultures, drainage cultures with sensitivity, Infectious Diseases consult CT scan of chest. Site drainage cultures are positive and CT shows an abscess in the fascia. Wound site is opened and packed. for 4 days until fever improves. CT Surgery Isolated CABG + Wound opening + Wound Packing 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. ID Consult hours DEEP INCISIONAL + Wound opening + Wound vacuum dressing (x 3 days) Repeat CT Scan + Wound debridement in operating room + Wound vac x 3 days + Daily wound dressing x 2 weeks Possible IV abx Discharge to Home Visiting Nurse Home visits + Wound dressing + Home Wound Vacuum follow-up : One of the following is CT Scan Thorax w/contrast One of the following is prescribed x 7 prescribed x 4 days (changed to oral days (assuming IV change to oral): antibiotics once the patient feels better): 1. Cephalexin cap 1. Levofloxacin IV 2. Levofloxacin tab 2. Cefazolin IV 3. Augmentin tab ICU Costs x 3 days Complete Blood Count once a day x 7 days Blood Draw x 8 Blood Cultures x 6 General Bacterial Culture once a day x 7 days once a day x 7 days Antibiotic susceptibility once a day x 7 days Room Costs x 4 days CBC (CPT 85027) Blood Draw (CPT 36415) Blood Culture (CPT 87040) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility(cpt 87186) CT Scan Thorax w/contrast (CPT 71260) Levofloxacin IV Cefazolin IV Levofloxacin tab Augmentin tab Wound Dressing Semiprivate Room Private Room ICU

20 WORKSHEET 2.2: Deep Incisional Mediastinal 7 Scenario: 70-year-old male 2 days post-op CABG develops fever of F, pain and redness at surgical site. Doctor orders CBC, blood cultures with sensitivity, Infectious Diseases consult. CT scan of chest. for 4 days until fever improves. Repeat CT scan. Wound site is opened and packed. Wound vacuum daily x 3 days, then daily dressing care for remainder of inpatient stay. CT Surgery Isolated CABG + Wound opening + Wound Packing 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. ID Consult hours DEEP INCISIONAL + Wound opening + Wound vacuum dressing (x 3 days) Repeat CT Scan + Wound debridement in operating room + Wound vac x 3 days + Daily wound dressing x 2 weeks Possible IV abx Discharge to Home Visiting Nurse Home visits + Wound dressing + Home Wound Vacuum follow-up CT Scan Thorax w/contrast Complete Blood Count once a day x 9 days Blood Draw x 10 Blood Culture x 6 Wound Culture x 2 x 2 Antibiotic susceptibility x2 : One of the following is prescribed x 4 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV : 7 days (assuming IV change to oral): 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab Room Costs x 6 days ICU Costs x 3 days CBC (CPT 85027) Blood Draw (CPT 36415) Blood Culture (CPT 87040) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) Levofloxacin IV Cefazolin IV CT Scan Thorax w/contrast (CPT 71260) Wound Vacuum & Wound Care Levofloxacin tab Augmentin tab Semiprivate Room Private Room ICU

21 WORKSHEET 2.3: Deep Incisional Mediastinal 8 Scenario: 57-year-old male 4 days post-op CABG develops fever of F, pain, redness at surgical site and purulent drainage from deep within the incision site. Physician orders CBC, blood cultures, drainage culture with sensitivity, Infectious Diseases consult, and CT scan of chest. for 4 days until fever improves. Repeat CT scan shows worsening. Patient goes to OR for wound I & D. Wound site is opened and packed. Wound vacuum daily x 3 days. CT Surgery Isolated CABG + Wound opening + Wound Packing 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. ID Consult hours DEEP INCISIONAL + Wound opening + Wound vacuum dressing (X3 days) Repeat CT Scan + Wound debridement in operating room + Wound vac x 3 days + Daily wound dressing x 2 weeks Possible IV abx Discharge to Home Visiting Nurse Home visits + Wound dressing + Home Wound Vacuum follow-up CT Scan Thorax w/contrast x2 Complete Blood Count once a day x 10 days Blood Draw x 11 Blood Culture x 6 General Bacterial Culture x3 x3 Antibiotic susceptibility x3 : One of the following is prescribed x 4 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV Anesthesia Supplies Debridement) OR Cost PACU Cost : 7 days (assuming IV change to oral): 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab Room Costs x 6 days ICU Costs x 4 days CT Scan Thorax w/contrast (CPT 71260) CBC (CPT 85027) Blood Draw (CPT 36415) Blood Culture (CPT 87040) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) Levofloxacin IV Cefazolin IV Wound Vacuum (97605GP) Wound Debridement in OR (97597GP) Wound Care Levofloxacin tab Augmentin tab Semiprivate Room Private Room ICU

22 9 ORGAN/SPACE SURGICAL-SITE INFECTIONS MEDIASTINAL Pathway 3 CT Surgery Isolated CABG hours 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. BLOOD Culture 6. CHEST X-ray 7. Urinalysis 8. ID Consult Below Bone ORGAN/ SPACE Conservative management + CT guided or subxiphoid + Operating room /debridement/rewire ICU care Possible Return to OR hours for flap coverage If Sternum non-viable Intubation for hours with multiple CXR, ABG, WBC Counts, Electrolytes, Creatinine, etc. Floor care Discharge follow-up

23 WORKSHEET 3.1: Organ/Space Mediastinal 10 Scenario: 57-year-old male 2 days post-op CABG develops fever of F. Patient complains of chest pain; surgical site is red and purulent. Doctor orders CBC, blood cultures with sensitivity, Infectious Diseases consult, and X-ray and CT scan of chest. CT scan shows pericardial effusion and patient is taken to OR for I & D and rewire. Wound site is opened and packed. Wound vacuum daily x 3 days. Patient remains intubated post-surgery. for 4 days until fever improves. Patient s fever resolves; moved to MedSurg. Repeat CBC and X-ray. Patient is sdsc discharged agedwith 4-6 weeks oral antibiotics. CT Surgery Isolated CABG hours 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. BLOOD Culture 6. CHEST X-ray 7. Urinalysis 8. ID Consult Below Bone ORGAN/ SPACE Conservative management + CT guided or subxiphoid + Operating room /debridement/rewire ICU care Possible Return to OR hours for flap coverage If Sternum non-viable Intubation for hours with multiple CXR, ABG, WBC Counts, Electrolytes, Creatinine, etc. Floor care Discharge follow-up CT Scan Thorax Complete Blood Count once a day x 8 days Blood Draw x 10 General Bacterial Culture x 2 x 2 Blood Culture x 4 Antibiotic susceptibility x2 x 4 days: Vancomycin IV Wound debridement in OR Chest X-Ray x 6 ABG x 6 CMP x 10 : 4-6 weeks (assuming IV change to oral): 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab 4. Metronidazole tab Anesthesia Supplies Debridement) OR Cost PACU Cost ICU Costs x 6 days Room Costs x 10 days CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) Blood Culture (CPT 87040) Urinalysis, routine (CPT 81001) : Vancomycin IV CT Scan Thorax w/contrast (CPT 71260) Wound Debridement in OR Chest X-ray PA & Lateral (CPT 71020) CMP (CPT 80053) ABG (CPT 82805) Levofloxacin tab Augmentin tab Metronidazole tab Semiprivate Room Private Room ICU

24 WORKSHEET 3.2: Organ/Space Mediastinal 11 Scenario: 57-year-old male 2 days post-op CABG develops fever of F. Patient complains of chest pain; surgical site is red and purulent. Doctor orders CBC, blood cultures with sensitivity, Infectious Diseases consult, and CT scan of chest. CT scan shows pericardial effusion and patient is taken to OR for I & D and rewire. Wound site is opened and packed. Wound vacuum daily x 3 days. Patient remains intubated postsurgery. 2 days post-i & D, patient is returned to OR for flap coverage. for 4 days until fever improves. Patient s fever resolves; moved to MedSurg. Repeat CBC C and X-ray. Patient t is discharged with 4-6 weeks oral antibiotics. CT Surgery Isolated CABG hours 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. BLOOD Culture 6. CHEST X-ray 7. Urinalysis 8. ID Consult Below Bone ORGAN/ SPACE Conservative management + CT guided or subxiphoid + Operating room /debridement/rewire ICU care Possible Return to OR hours for flap coverage If Sternum non-viable Intubation for hours with multiple CXR, ABG, WBC Counts, Electrolytes, Creatinine, etc. Floor care Discharge follow-up CT Scan Thorax Complete Blood Count once a day x 8 days Blood Draw x 10 General Bacterial Culture x 2 x 2 Blood Culture x 4 Antibiotic susceptibility x2 x 4 days: Vancomycin IV Wound debridement in OR Chest X-Ray x 6 ABG x 6 CMP x 10 : 4-6 weeks (assuming IV change to oral): 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab 4. Metronidazole tab OR for I&D, Return for flap Anesthesia Supplies x2 Debridement) x1 OR Cost x2 PACU Cost x2 Skin Graft x 1 ICU Costs x 8 days Room Costs x 10 days CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) Blood Culture (CPT 87040) Urinalysis, routine (CPT 81001) : Vancomycin IV CT Scan Thorax w/contrast (CPT 71260) Wound Debridement in OR Chest X-ray PA & Lateral (CPT 71020) CMP (CPT 80053) ABG (CPT 82805) Levofloxacin tab Augmentin tab Metronidazole tab Semiprivate Room Private Room ICU Total Parental Nutrition

25 WORKSHEET 3.3: Organ/Space Mediastinal 12 Scenario: 57-year-old male 2 days post-op CABG develops fever of F, complains of pain and redness at surgical site. Doctor orders CBC, blood cultures with sensitivity, Infectious Diseases consult and CT scan. X-ray of chest show shows no improvement after for 4 days. Repeat CT scan shows pericardial effusion. Doctor performs CT-guided drainage tube placement. CT Surgery Isolated CABG hours 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. BLOOD Culture 6. CHEST X-ray 7. Urinalysis 8. ID Consult Below Bone ORGAN/ SPACE Conservative management + CT guided or subxiphoid + Operating room /debridement/rewire ICU care Possible Return to OR hours for flap coverage If Sternum non-viable Intubation for hours with multiple CXR, ABG, WBC Counts, Electrolytes, Creatinine, etc. Floor care Discharge follow-up CT Scan Thorax x 1 Chest X-Ray x 1 Complete Blood Count once a day x 8 days Blood Draw x 10 General Bacterial Culture x 2 x 2 Blood Culture x 4 Antibiotic susceptibility x 2 : One of the following is prescribed 4 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV 3. Piperacillin/Tazobactam IV 4. Metronidazole Premix 5. Vancomycin IV CT Guided Conscious Sedation : 7 days (assuming IV change to oral): 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab 4. Metronidazole tab ICU Costs x 4 days Room Costs x 4 days CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) Blood Culture (CPT 87040) Urinalysis, routine (CPT 81001) CT Scan Thorax w/contrast (CPT 71260) Chest X-ray PA & Lateral (CPT 71020) : Levofloxacin IV Cefazolin IV Piperacillin/Tazobactam IV Metronidazole Premix Vancomycin IV Tube Pericardiostomy (CPT 33015) CT Guidance (75989) Conscious Sedation (99144) Levofloxacin tab Augmentin tab Metronidazole tab Semiprivate Room Private Room ICU Total Parental Nutrition

26 WORKSHEET 3.4: Organ/Space Mediastinal 13 Scenario: 63-year-old female, 2 days post-op CABG, develops fever of F, pain and redness at surgical site. Doctor orders CBC, blood cultures with sensitivity, Infectious Diseases consult CT scan of chest. for 4 days until fever improves. Doctor decides to pursue conservative management. CT Surgery Isolated CABG hours 1. WBC COUNT 2. CT scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. BLOOD Culture 6. CHEST X-ray 7. Urinalysis 8. ID Consult Below Bone ORGAN/ SPACE Conservative management + CT guided or subxiphoid + Operating room /debridement/rewire ICU care Possible Return to OR hours for flap coverage If Sternum non-viable Intubation for hours with multiple CXR, ABG, WBC Counts, Electrolytes, Creatinine, etc. Floor care Discharge follow-up CT Scan Thorax x 1 Chest X-Ray x 1 Complete Blood Count once a day x 8 days Blood Draw x 10 General Bacterial Culture x 2 x 2 Blood Culture x 4 Antibiotic susceptibility x 2 : One of the following is prescribed 4 days (changed to oral antibiotics once the patient feels better): 1. Levofloxacin IV 2. Cefazolin IV 3. Piperacillin/Tazobactam IV 4. Metronidazole Premix 5. Vancomycin IV : 7 days (assuming IV change to oral): 1. Cephalexin cap 2. Levofloxacin tab 3. Augmentin tab 4. Metronidazole tab ICU Costs x 4 days Room Costs x 4 days CBC (CPT 85027) Blood Draw (CPT 36415) General Bacterial Culture (CPT 87070) (CPT 87205) Antibiotic susceptibility (CPT 87186) Blood Culture (CPT 87040) Urinalysis, routine (CPT 81001) CT Scan Thorax w/contrast (CPT 71260) Chest X-ray PA & Lateral (CPT 71020) : Levofloxacin IV Cefazolin IV Piperacillin/Tazobactam IV Metronidazole Premix Vancomycin IV Levofloxacin tab Augmentin tab Metronidazole tab Semiprivate Room Private Room ICU

27 1 SUPERFICIAL SURGICAL-SITE INFECTIONS NEURO SUPERFICIAL Spinal Surgery Laminectomy *No hardware or hardware No fever Mild For 2 weeks 1-10 days CBC, CRP culture deep Q-tip probe 7 days if no change or worse SUPER- FICIAL INCISIONAL + Wound vacuum + Wound opening + Wound packing Daily Wound Dressing Discharge to Home follow-up x 2 visits Visiting Nurse to change wound dressing Weekly home visits x 3 visits

28 WORKSHEET 1.1: SUPERFICIAL Neuro Surgery 2 Scenario: A 48-year-old woman presented with localized pain at the incision. 2 weeks previously underwent an L4-5 laminectomy. Now noticed some redness at the wound site. No fevers or chills. Doctor orders CBC, CRP,. Superficial. Oral antibiotic for 14 days. Spinal Surgery Laminectomy *No hardware No fever Mild For 2 weeks days CBC, CRP Culture deep Q-tip Probe CT Scan 7 days if no change or worse SUPER- FICIAL INCISIONAL + Wound vacuum + Wound opening + Wound packing Daily Wound Dressing Discharge to Home follow-up x 2 visits Visiting Nurse to change wound dressing Weekly home visits x 3 visits CODING Complete Blood Count every 7 days x 2 Blood Draw x 2 days C-Reactive Protein x 2 days x 2 days : One of the following is prescribed x 14 days: 4 Cephalexin 500 tab 2 Bactrim 2DS 4 Dicloxacillin 500 mg tab CODING REIMBURSE- MENT AND COST CBC (CPT 85027) Blood Draw (CPT 36415) CRP (CPT 86141) (87205) Bactrim 2DS Dicloxacillin

29 3 SUPERFICIAL SURGICAL-SITE INFECTIONS NEURO DEEPER Spinal Surgery Laminectomy *No hardware No fever Mild For 2 weeks 1-10 days CBC, CRP culture deep Q-tip SUPER- FICIAL INCISIONAL + Wound vacuum Discharge to Home follow-up x 2 visits probe 7 days if no change or worse + Wound opening + Wound packing Daily Wound Dressing Visiting Nurse to change wound dressing Weekly home visits x 3 visits

30 WORKSHEET 2.1: Deeper Neuro Surgery 4 Scenario: A 52-year-old male presented with localized pain at the incision. 4 weeks previously underwent an L4-5 laminectomy, no hardware or bone graft. Noticed some redness at the wound site two weeks earlier and treated with antibiotics, but patient failed to improve. Now Q-tip can be extended deeper below the fascia with some fluid noted. Has fevers and some chills. CT shows abscess. Open drainage is required and he requires hospitalization x 2 days., wound vacuum, and dressing. Patient improves; issue resolved. Spinal Surgery Laminectomy * No hardware For 2 weeks 7-10 days CBC q 7 d CRP q 2-3 weeks CT scan+ contrast DEEPER INCISIONAL x 10 d Discharge to + Wound vacuum Home follow-up q 7 d x 3 7 days x 3 x 10 d + Wound opening + Wound packing + Wound vac Daily Wound Dressing In hospital & home Visiting Nurse Home visits weekly x 3 + Wound dressing/ Home Wound Vac CODING Complete Blood Count x 3 CRP x 2 Blood Draw (36415) : One or both of the following are prescribed for 7-10 days: Vancomycin IV Cefepime IV Wound vac Wound dressing : One of the following is prescribed for 14 days: 2 Bactrim 2DS cap 1 Levofloxacin 400 mg 2 Cefpodoxime proxitel 400 mg CODING REIMBURSE- MENT AND COST CBC (CPT 85027) CRP (CPT 86140) Blood Draw (CPT 36415) Vancomycin Cefepime Bactrim Levofloxacin Cefpodoxime

31 5 SUPERFICIAL SURGICAL-SITE INFECTIONS NEURO DEEP, HARDWARE Spinal Surgery Laminectomy * hardware Then Oral Antibiotics For 3-6 months 4-6 weeks CBC q 7 d CRP q 2-3 weeks CT scan+ contrast DEEP INCISIONAL + Wound vacuum Discharge to Home follow-up Repeat CBC count in hours, then q 7 days Daily Wound Dressing + Wound opening + Wound packing +Wound vacuum Visiting Nurse Home visits + Wound dressing/ Home Wound Vac

32 WORKSHEET 2.2: DEEP, HARDWARE Neuro Surgery 6 Scenario: A 48-year-old male presented with localized pain at the incision. 4 weeks previously underwent a L4-5 laminectomy, hardware or bone graft placed. Noticed some redness at the wound site two weeks earlier and treated with antibiotics, but patient failed to improve. Now Q-tip can be extended deeper below the fascia with some fluid noted. Has fevers and some chills. If CT shows abscess, open drainage is required and he requires hospitalization x 2-3 days. All deep wound infections require wound vacuum dressings x several weeks and patients with hardware or bone grafts require e much more prolonged o antibiotic treatment. e t Spinal Surgery Laminectomy * hardware Then Oral Antibiotics For 3-6 months 4-6 weeks CBC q 7 d CRP q 2-3 weeks CT scan+ contrast DEEP INCISIONAL + Wound vacuum Discharge to Home follow-up Repeat CBC count in hours, then q 7 days Daily Wound Dressing + Wound opening + Wound packing +Wound vacuum Visiting Nurse Home visits + Wound dressing/ Home Wound Vac CODING Complete Blood Count q 7 days x 2 then once per month CRP once per month until WNL Blood Draw : One or both of the following are prescribed for 7-10 days: Vancomycin IV Cefepime IV Wound vacuum x 4 days (Assuming patient required Wound Vacuum only in hospital) - There is no billing event for daily wound dressing Nursing time. : One of the following is prescribed for 3-6 months: 2 Bactrim 2DS cap 1 Levofloxacin 400 mg 2 Cefpodoxime proxitel 400 mg CODING REIMBURSE- MENT AND COST CBC (CPT 85027) CRP (CPT 86140) Blood Draw (CPT 36415) Vancomycin IV Cefepime IV Wound opening and debridement Wound Vacuum Daily wound dressing: not billed Bactrim Levofloxacin Cefpodoxime proxitel

33 7 SUPERFICIAL SURGICAL-SITE INFECTIONS NEURO VERY DEEP, CRANIOTOMY Craniotomy Skull infection Bone removal Prosthesis replacement Then Oral Antibiotics for 1-2 wks 3-4 weeks CBC q 7 days CRP q 2-3 weeks CT scan w/contrast DEEP INCISIONAL + Wound debridement Discharge to Home follow-up x 5 Repeat CBC count in hours, then q 7 days Daily Wound Dressing daily + Wound debridement + Wound packing +Skull bone removal Replace at 6 mo Visiting Nurse Home visits + Wound dressing/ daily visit while on home IVs

34 WORKSHEET 3.1: VERY DEEP, Craniotomy Neuro Surgery 8 Scenario: A 55-year-old WF, s/p frontal craniotomy for resection of a meningioma, admitted with redness, and purulent discharge from the area of the incision associated with fever and mild pain. Patient is given for 7-10 days. Because the scalp is directly over the bone, all craniotomy infections turn out to be deep infections. Patient taken to OR for debridement and skull bone removal and replacement of prosthetic. Patient improves and is discharged with oral antibiotics. Readmitted 6 months after removal for prosthetic skull replacement. Craniotomy Skull infection Bone removal Prosthesis replacement Then Oral Antibiotics for 1-2 wks 3-4 weeks CBC q 7 days CRP q 2-3 weeks CT scan w/contrast DEEP INCISIONAL Discharge to + Wound Home follow-up x 5 debridement CODING Repeat CBC count in hours, then q 7 days Complete Blood Count q 7 days x 2, then once per month CRP once per month until WNL Blood Draw : One or both of the following are prescribed for 7-10 days: Vancomycin IV Cefepime IV Daily Wound Dressing daily + Wound debridement + Wound packing +Skull bone removal Replace at 6 mo OR for opening & debridement of wound Remove and replace skull bone with methacrylate prosthesis Visiting Nurse Home visits + Wound dressing/ daily visit while on home IVs : One of the following is prescribed for 1-2 wks: 2 Bactrim 2DS cap 1 Levofloxacin 500 mg 2 Cefpodoxime proxitel 400 mg CODING REIMBURSE- MENT AND COST CBC (CPT 85027) CRP (CPT 86140) Blood Draw (CPT 36415) CT scan w/contrast (CPT 72132) Vancomycin IV Cefepime IV Wound opening and debridement Skull bone removal (CPT 62142) Readmission with prosthetic skull replacement (CPT 62143) Daily wound dressing: not billed Visiting nurse Bactrim Levofloxacin Cefpodoxime proxitel

35 1 SURGICAL-SITE ORTHOPEDIC INFECTIONS TOTAL JOINT REPLACEMENT Knee Superficial OUT Evaluation TOTAL JOINT REPLACEMENT Follow-up Less than 6 weeks History Exam Superficial Observation Oral antibiotics x 7-10 days follow-up 7-10 days Wound Incisional redness Swelling draining Operative I&D of Wound OUT If ROM is and/or is Wound culture Joint aspiration Culture & sensitivity Culture & Sensitivity Incision Closed Patient Follow-up 2 weeks Continue Rehab Resolved

36 WORKSHEET 1.1: ORTHOPEDIC TOTAL JOINT REPLACEMENT Knee Superficial OUT 2 Scenario: 75 yo female who underwent knee surgery. Follow-up 2 weeks post-op. Presents with redness and swelling; superficial. Joint aspiration, labs, and culture. Doctor put patient on Cephalexin for 7 days. Patient improves and issue is resolved. TOTAL JOINT REPLACEMENT Follow-up Less than 6 weeks Evaluation History Exam Superficial Observation Oral antibiotics x 7-10 days follow-up 7-10 days Wound Incisional redness Swelling draining i Operative I&D of fwound OUT If ROM is and/or is Wound culture Joint aspiration Culture & sensitivity Culture and Sensitivity Incision Closed Patient Follow-up 2 weeks Continue Rehab Resolved 1 Complete Blood Count with Differential 1 Blood Draw 1 Joint Aspiration 1 1 General Bacterial Culture 1 1 Antibiotic susceptibility 1 Protein: Body Fluid 1 Glucose: Body Fluid x 7 days (either one of following) 2 Cephalexin cap 1 Levofloxacin tab 1 CBC (85025) 1 Blood Draw (36415) 1 Joint Aspiration (20610) 1 (89051) 1 General Bacterial Culture (87070) 1 (87205) 1 Antibiotic susceptibility (87186) 1 Protein: Body Fluid (84157) 1 Glucose: Body Fluid (82945) Levofloxacin tab

37 WORKSHEET 1.2: ORTHOPEDIC TOTAL JOINT REPLACEMENT Knee Superficial OUT 3 Scenario: 62 yo patient who underwent knee surgery 2 weeks post-operative presents with superficial wound/incisional infection/cellulitis. Joint aspiration and labs: fluid cell count; aerobic/anaerobic culture & sensitivity; gram stain; protein; glucose days Cephalexin/Cipro. 7 days later still shows redness and decreased range of motion. Doctor performed incisional I & D wound operating room pulse lavage. Labs: fluid cell count, culture, gram stain. Continues antibiotics for 7 days. Resolves. TOTAL JOINT REPLACEMENT Follow-up Less than 6 weeks Evaluation History Exam Superficial Observation Oral antibiotics x 7-10 days follow-up 7-10 days Wound Incisional redness Swelling draining i Operative I&D of fwound OUT If ROM is and/or is Wound culture Joint aspiration Culture & sensitivity Protein, Glucose Culture and Sensitivity Incision Closed Patient Follow-up 2 weeks Continue Rehab Resolved 1 Complete Blood Count with Differential 1 Blood Draw 1 Joint Aspiration x 2 General Bacterial Culture x 2 x 2 Antibiotic susceptibility x 2 Protein: Body Fluid Glucose: Body Fluid Knee Incision and drainage Operating Room x 14 days (either one of following) 2 Cephalexin cap 1 Levofloxacin tab CBC (85025) Blood Draw (36415) Joint Aspiration (20610) (89051) General Bacterial Culture (87070) (87205) Antibiotic susceptibility (87186) Protein: Body Fluid (84157) Glucose: Body Fluid (82945) Knee Incision (27301) OR Levofloxacin tab

38 4 SURGICAL-SITE ORTHOPEDIC INFECTIONS TOTAL JOINT REPLACEMENT Knee Superficial Deep Infection OUT Evaluation TOTAL JOINT REPLACEMENT Follow-up within 6 Weeks Post-op History Exam Wound Incisional redness Swelling Draining Wound culture Joint aspiration Culture & sensitivity Aspirate WC >20K Subfascial Empiric Pending Admit Surgery Operative I&D of Wound Replacement of Poly Spacer OUT Culture & Sensitivity Incision Closed ID Consult PICC Line placed 6 Weeks Patient Followed up and Resolved

39 WORKSHEET 2.1: ORTHOPEDIC TOTAL JOINT REPLACEMENT Knee Subfascial OUT 5 Scenario: Scenario: 60 yo female seen 3 weeks after knee replacement surgery with a swollen, tender wound with yellow drainage. Intermittent temperature of 99.5 F without chills. Deep wound subfascial infection. culture for aerobic/anaerobic culture/sensitivity; gram stain/cell count. Wound needle aspiration for culture/sensitivities followed by outpatient OR procedure mins. Incision/irrigation/closed drainage. Anesthesia: general/mac. Lab: Tissue culture aerobic/anaerobic; gram stain/cell count. PICC line for 6 weeks of as outpatient. t Resolved. ed TOTAL JOINT REPLACEMENT Follow-up within 6 Weeks Post-op Evaluation History Exam Wound Incisional redness Swelling Draining Wound culture Joint aspiration Culture & sensitivity Aspirate WC >50K Subfascial Empiric Oral antibiotics Pending Admit Surgery Operative I&D of Wound Replacement of Poly Spacer OUT Culture & Sensitivity Incision Closed ID Consult PICC Line placed 6 Weeks Patient Followed up and Resolved 1 Complete Blood Count with Differential 1 Blood Draw 1 Joint Aspiration 1 x 3 days 1 General Bacterial Culture x 3 days 1 x 3 days 1 Antibiotic susceptibility x 3 days 1 Protein: Body Fluid 1 Glucose: Body Fluid x 7 days (either one of following) 2 Cephalexin cap 1 Levofloxacin tab Knee Incision and drainage Replacement of poly spacer Anesthesia supplies Operating Room PACU PICC Line Insertion & Kit : One of the following is prescribed x 8 days: 1. Levofloxacin IV 2. Cefazolin IV CBC (85025) Blood Draw (36415) Joint Aspiration (20610) (89051) General Bacterial Culture (87070) (87205) Antibiotic susceptibility (87186) Protein: Body Fluid (84157) Glucose: Body Fluid (82945) Levofloxacin tab Knee Incision and drainage (27301) Replacement of poly spacer (27488) Anesthesia supplies (IP#90889) OR PACU (IP#10230) PICC Line Insertion & Kit (36569) IVAntibiotics Levofloxacin IV Cefazolin IV

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