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Hasan SH, Ali U, Khan J, Pidani AS, Jivani N, Ziauddin A, Zafar H, Noordin S. Orthopaedic Surgery Complications at a Tertiary Care Hospital in a Low- and Middle-Income Country: A National Surgical Quality Improvement Project Analysis. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202310000-00012. [PMID: 37867254 PMCID: PMC10593258 DOI: 10.5435/jaaosglobal-d-23-00074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Through a comparison of orthopaedic surgical procedures performed at a tertiary care hospital in Pakistan with other participating hospitals of National Surgical Quality Improvement Project (NSQIP), we aim to identify the areas of orthopaedic surgical care at our center that need improvement and also those which are at par with international standards. METHODS The study analyses orthopaedic surgeries at a tertiary care hospital in Pakistan using NSQIP registry to compare complication rates with other American College of Surgeons-NSQIP participant hospitals. Two reviewers collect data in different days every 8 days to reduce bias, and the results are reported in odds ratios using quarterly reports. This study included 584 eligible orthopaedic cases performed in 2021. Yearly institutional reports with odds ratios were also used to identify areas needing improvement and to implement changes to improve orthopaedic surgical outcomes at said institute. RESULTS The quarterly reports suggest a relatively higher OR for certain indicators such as cardiac events, surgical site infection, mortality, and morbidity throughout. The renal failure rate was very high in the third and fourth quarters with odds ratios of 4.57 and 10.31, respectively. However, the official NSQIP annual institutional report for 2021 identified sepsis, surgical site infections, and cardiac complications as areas 'needing improvement'. It also indicated that the hospital performed exemplarily when it came to venous thromboembolism (VTE). As for the rest of the indicators, the hospital fell in the 'as expected' category of the NSQIP standards. CONCLUSION This initial report helps the hospital's orthopaedic department in recognizing areas for improvement and making system-level changes to improve patient outcomes. The implementation of these interventions has yielded favorable outcomes, as evidenced by the findings in the NSQIP yearly report for 2022. Reinforcements and measures are needed to be taken to reduce the adverse events even further and to improve the patient outcomes and quality.
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Affiliation(s)
- Syed Hashir Hasan
- From the Department of Orthopaedic Surgery, Aga Khan University Hospital, Karachi, Pakistan (Dr. Hasan, Dr. Ali, Dr. Khan and Dr. Noordin); Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan (Dr. Zafar); Department of Infection Prevention & Hospital Epidemiology, Aga Khan University Hospital, Karachi, Pakistan (Ms. Jivani and Ms. Ziauddin); University of Toronto, Ontario, Canada (Ms. Pidani)
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Mo K, Gupta A, Al Farii H, Raad M, Musharbash F, Tran B, Zheng M, Lee SH. 30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors. J Spine Surg 2022; 8:204-213. [PMID: 35875628 PMCID: PMC9263737 DOI: 10.21037/jss-22-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy. METHODS The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected. RESULTS Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037). CONCLUSIONS These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.
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Affiliation(s)
- Kevin Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Arjun Gupta
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Humaid Al Farii
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Farah Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Britni Tran
- Western University of Health Sciences, Pomona, CA, USA
| | - Ming Zheng
- Western University of Health Sciences, Pomona, CA, USA
| | - Sang Hun Lee
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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Duquette E, Bhatti P, Sur S, Felbaum DR, Dowlati E. The History and Use of Antibiotic Irrigation for Preventing Surgical Site Infection in Neurosurgery: A Scoping Review. World Neurosurg 2022; 160:76-83. [DOI: 10.1016/j.wneu.2022.01.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 11/28/2022]
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Chacón-Quesada T, Rohde V, von der Brelie C. Less surgical site infections in neurosurgery during COVID-19 times-one potential benefit of the pandemic? Neurosurg Rev 2021; 44:3421-3425. [PMID: 33674981 PMCID: PMC7935474 DOI: 10.1007/s10143-021-01513-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 01/28/2023]
Abstract
Hygiene measures were intensified when the COVID-19 pandemic began. Patient contacts were limited to a minimum. Visitors were either not allowed for a certain period or limited for the rest of the time. The hospital staff began to wear masks and gloves continuously. Clinical examinations and routine wound controls were also performed under intensified hygiene standards. These circumstances result in a limitation of direct physical interactions between the nursing staff, the physicians and the patients. We analyzed to what extent the intensification of hygiene measures affects the rate of surgical site infections (SSI) after neurosurgical procedures. The rate of SSI during the 6-month interval after the beginning of COVID-19 measures was compared with the SSI rate before. The numbers of the period before COVID-19 were analyzed as mean values resulting from the analysis of two separate time periods each consisting of 6 months. The spectrum of surgical procedures was compared. Patient-related risk factors for SSIs were noted. Microorganisms were analyzed. We focused on SSIs occurring at a maximum of 60 days after the primary surgery. Overall, in the two respective 6-month periods before COVID-19, a mean of 1379 patients was surgically treated in our institution. After the beginning of COVID-19 (starting from 04/2020) our surgical numbers dropped by 101, resulting in a total number of 1278 patients being operated after 03/2020 until 09/2020. The SSI rate was 3.6% (03/2019-09/2019, 50 SSIs) and 2.2% (09/2019-03/2020, 29 SSIs), resulting in a mean of 2.9% before COVID-19 began. After the beginning of COVID-19 hygiene measures, this rate dropped to 1.4% (16 SSIs) resembling a significant reduction (p=0.003). Risk factors for the development of SSI were present in 81.3% of all patients. Pre- and post-COVID-19 patient groups had similar baseline characteristics. The same holds true when comparing the percentage of cranial and spinal procedures pre- and post-COVID-19 (p=0.91). Comparing the numbers (p=0.28) and the species (p=0.85) of microorganisms (MO) causing SSI, we found a similar distribution. Despite equal demographics and characteristics of SSI, the rate of SSI dropped substantially. This argues for an effective reduction of postoperative SSI resulting from the implementation of strict hygiene measures being established after the beginning of the COVID-19 pandemic. We therefore advocate continuing with strict and intensive hygiene measures in the future.
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Affiliation(s)
- T Chacón-Quesada
- Department of Neurosurgery, Georg August University of Göttingen, Göttingen, Germany
| | - V Rohde
- Department of Neurosurgery, Georg August University of Göttingen, Göttingen, Germany
| | - C von der Brelie
- Department of Neurosurgery, Georg August University of Göttingen, Göttingen, Germany.
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Hussain MM, Bibi F, Shah S, Mitha R, Shamim MS, Ziauddin A, Zafar H. First American College of Surgeons National Surgical Quality Improvement Program Report from a Low-Middle-Income Country: A 1-Year Outcome Analysis of Neurosurgical Cases. World Neurosurg 2021; 155:e156-e167. [PMID: 34403795 DOI: 10.1016/j.wneu.2021.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Low-middle-income countries (LMICs) share a substantial proportion of global surgical complications. This is compounded by the seemingly deficient documentation of postsurgical complications and the lack of a national average for comparison. In this context, the implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) that compares hospital performance based on postsurgical complication data provided by a wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of the NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To our knowledge, this report is the first from an LMIC to report its postoperative neurosurgical complications in comparison with international benchmarks. METHODS Our hospital joined the NSQIP in 2019. Through a standardized ACS protocol, ACS-trained surgical clinical reviewers (SCRs) reviewed and extracted data from randomly assigned neurosurgical patients' medical records from preoperative to postoperative (30-day) data using validated, standardized data definitions. SCRs entered deidentified data in an online Health Insurance Portability and Accountability Act web-based secure platform. The validated data were then consigned to the ACS NSQIP head office in the United States where the data were analyzed and compared with similar data from other centers registered with the NSQIP. In this way, our hospital was rated for each of the variables related to postsurgical complications after both spinal and cranial procedures, and the results were sent back to us in the form of text, tables, and graphs. RESULTS Our initial report suggested a relatively higher odds ratio for sepsis and readmissions after spinal procedures at our hospital, and a similarly higher odds ratio for morbidity, sepsis, urinary tract infection, and surgical site infection for cranial procedures. For these variables, our hospital fell in the needs improvement category of the NSQIP. For the rest of the variables studied for both spinal and cranial procedures, the hospital fell in the as expected category of the NSQIP. CONCLUSIONS Implementation of the NSQIP is an important first step in creating a culture of transparency, safety, and quality. This is the first report of NSQIP implementation in an LMIC, and we have shown comparable results to developed countries.
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Affiliation(s)
- Mustafa Mushtaq Hussain
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Farida Bibi
- Neurology and Neurosurgery Nursing, Aga Khan University Hospital, Karachi, Pakistan
| | - Shafqat Shah
- Neurology and Neurosurgery Nursing, Aga Khan University Hospital, Karachi, Pakistan
| | - Rida Mitha
- Post-Graduate Medical Education, Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Shahzad Shamim
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
| | - Afsheen Ziauddin
- Quality and Patient Safety Office, Aga Khan University Hospital, Karachi, Pakistan
| | - Hasnain Zafar
- Quality and Patient Safety Office, Aga Khan University Hospital, Karachi, Pakistan
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Lepski G, Reis B, de Oliveira A, Neville I. Recursive partitioning analysis of factors determining infection after intracranial tumor surgery. Clin Neurol Neurosurg 2021; 205:106599. [PMID: 33901746 DOI: 10.1016/j.clineuro.2021.106599] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Several factors are commonly associated with the occurrence of post-operative infection after craniotomy. However, the risk factors associated with tumor surgery have been less intensively investigated. The aim of the present study was to analyze the risk factors for infection and categorize patients according to risk rate. METHODS In this study, we retrospectively evaluated 987 adult patients consecutively submitted to craniotomy for tumor resection. The primary outcome was the occurrence of infection within 30 days after surgery. The following independent variables were assessed: age, gender, surgery duration, length of hospital stay prior to surgery, reoperation, body mass index, serum albumin, hemoglobin, lactic dehydrogenase, smoking, diabetes, corticoid use, preoperative chemotherapy, previous irradiation, elective or urgent indication for surgery, supra or infratentorial lesion location, and tumor histology. We performed a recursive partitioning analysis to assess the relative importance of these variables in predicting infection. RESULTS The model returned a 3-level classification: 1. CSF-leakage (relative contribution 70%), 2. Emergency surgery indication (18%), and 3. Tumor histology (8%). Additionally, partitioning clustered together 3 risk groups: 1. CSF-leakage group (probability of infection 72.5%), 2. No CSF-leakage and urgent surgery (mean probability 18.1%); and 3. no CSF-leakage and no urgent surgery (3.4%). The misclassification rate was 4.5%, the overall specificity and sensitivity were 99.6% and 75.5%, respectively, and the area under the ROC-curve was 0.6908. CONCLUSION Our analysis indicates that technical and treatment-related factors are significantly more relevant than patient- or disease-related factors in determining the risk of postoperative infection.
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Affiliation(s)
- Guilherme Lepski
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, LIM26, São Paulo, Brazil; Department of Neurosurgery, University Eberhard Karls, Tübingen, Germany.
| | - Bruno Reis
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, LIM26, São Paulo, Brazil
| | - Adilson de Oliveira
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, LIM26, São Paulo, Brazil
| | - Iuri Neville
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, LIM26, São Paulo, Brazil
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