Evaluation of postdischarge surveillance of surgical site infections after total hip and knee arthroplasty

Patient understanding of and participation in infection-related care across surgical pathways: a scoping review

OBJECTIVE

To explore the existing evidence on patient understanding of and/or participation in infection-related care in surgical specialties.

METHOD

A scoping review of the literature was conducted. PubMed, Web of Science, Scopus, and grey literature sources were searched using predefined search criteria for policies, guidelines, and studies in the English language. Data synthesis was done through content and thematic analysis to identify key themes in the included studies.

RESULTS

The initial search identified 604 studies, of which 41 (36 from high-income and five from low- and middle-income countries) were included in the final review. Most of the included studies focused on measures to engage patients in infection prevention and control (IPC) activities, with few examples of antimicrobial stewardship (AMS) engagement strategies. While patient engagement interventions in infection-related care varied depending on study goals, surgical wound management was the most common intervention. AMS engagement was primarily limited to needs assessment, without follow-up to address such needs.

CONCLUSION

Existing evidence highlights a gap in patient participation in infection-related care in the surgical pathway. Standardization of patient engagement strategies is challenging, particularly in the context of surgery, where several factors influence how the patient can engage and retain information. Infection-related patient engagement and participation strategies in surgery need to be inclusive and contextually fit.

Epidemiologic characteristics of orthopedic surgical site infections and under-reporting estimation of registries using capture-recapture analysis

Background

Surgical Site Infections (SSIs) are among the leading causes of the postoperative complications. This study aimed at investigating the epidemiologic characteristics of orthopedic SSIs and estimating the under-reporting of registries using the capture-recapture method.

Methods

This study, which was a registry-based, cross-sectional one, was conducted in six educational hospitals in Tehran during a one-year period, from March, 2017 to March, 2018. The data were collected from two hospital registries (National Nosocomial Infection Surveillance System (NNIS) and Health Information Management database (HIM)). First, all orthopedic SSIs registered in these sources were used to perform capture-recapture (N = 503). Second, 202 samples were randomly selected to assess patients` characteristics.

Results

Totally, 76.24% of SSIs were detected post-discharge. Staphylococcus aureus (11.38%) was the most frequently detected bacterium in orthopedic SSIs. The median time between the detection of a SSI and the discharge was 17 days. The results of a study done on 503 SSIs showed that the coverage of NNIS and HIM was 59.95 and 65.17%, respectively. After capture-recapture estimation, it was found that about 221 of orthopedic SSIs were not detected by two sources among six hospitals and the real number of SSIs were estimated to be 623 ± 36.58 (95% CI, 552–695) and under-reporting percentage was 63.32%.

Conclusion

To recognize the trends of SSIs mortality and morbidity in national level, it is significant to have access to a registry with minimum underestimated data. Therefore, according to the weak coverage of NNIS and HIM among Iranian hospitals, a plan for promoting the national Infection Prevention and Control (IPC) programs and providing updated protocols is recommended.

Utilization of Drains and Association With Outcomes: A Population-Based Study Using National Data on Knee Arthroplasties

INTRODUCTION

Although surgical drains have been used routinely in total knee arthroplasties (TKAs), results from several large trials have led to recommendations against their use. Because national data are lacking, we aimed at assessing utilization patterns of drains and perioperative outcomes in TKA procedures.

METHODS

We included 1,130,124 TKA procedures from the national claims-based Premier Healthcare Database (2006 to 2016). Patients receiving a drain were compared with those who did not. Multivariable multilevel models measured associations between drain use and blood transfusions, postoperative infections, 30-day readmission, and length/cost of hospitalization. Odds ratios and 95% confidence intervals are reported. Propensity score analyses were performed to assess the robustness of results.

RESULTS

Drain use decreased from 33.0% (n = 22,901 of 69,370) in 2006 to 15.6% (n = 19,418 of 124,440) in 2016 and was particularly higher in large (>500 beds; 27.1%) and nonteaching hospitals (26.9%). After adjustment for relevant covariates, the use of drains (compared with no use) was significantly associated with increases in particularly blood transfusions (odds ratio, 1.27; 95% confidence interval, 1.24 to 1.30 n = 138,306 total transfusions), whereas minimal effects were seen for other outcomes. Propensity score analyses confirmed these results.

DISCUSSION

Although retrospective, the current study provides an important insight into real-world clinical practice regarding the use of drains. With current evidence not supporting their use in TKA, we found that national utilization is slowly decreasing. Moreover, because drain use is associated with negative outcomes, future studies should focus on drivers of their continued use.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Impact of patient comorbidities on surgical site infection within 90 days of primary and revision joint (hip and knee) replacement

BACKGROUND

The frequency of primary and revision total knee and hip replacements (pTKRs, rTKRs, pTHRs, and rTHRs, respectively) is increasing in the United States due to demographic changes. This study evaluated the impact of preoperative patient and clinical factors on the risk of surgical site infection (SSI) within the 90-day period after primary and revision total joint replacements (TJR).

METHODS

A retrospective observational cohort study was designed using the IBM MarketScan and Medicare databases, 2009-2015. Thirty-four comorbidities were assessed for all patients, and multivariable logistic regression models were used to evaluate factors associated with higher odds of SSI after adjusting for other patient and clinical preoperative conditions.

RESULTS

The study included a total of 335,134 TKRs and 163,547 THRs. SSI rates were 15.6% and 8.6% after rTKR and rTHR, respectively, compared with 2.1% and 2.1% for pTKR and pTHR, respectively. Comorbidities with the greatest adjusted effect on SSI across all TJRs were acquired immunodeficiency syndrome (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.06-2.34; P = .0232), paralysis (OR, 1.56; 95% CI, 1.26-1.94; P < .0001), coagulopathy (OR, 1.48; 95% CI, 1.36-1.62; P < .0001), metastatic cancer (1.48; 95% CI, 1.24-1.76; P < .0001), and congestive heart failure (OR, 1.39; 95% CI, 1.30-1.49; P < .0001).

CONCLUSIONS

SSI occurred most commonly among patients after revision TJR and were related to many patient comorbidities, including diabetes, congestive heart failure, and coagulopathy, which were significantly associated with a higher risk of SSI after TJR.

What is the Relationship Between Patients’ And Clinicians’ Reports of the Outcomes of Elective Surgery?

Objectives

To identify studies in which patients’ and clinicians’ reports of health status and complications of one of four elective operations - hip and knee replacement, varicose vein surgery and groin hernia repair - are reported, and to describe the associations that have been reported between clinicians’ and patients’ reports.

Methods

Systematic search of several bibliographic databases and review of citations of articles meeting inclusion criteria. A narrative summary of the findings was conducted.

Results

Most of the 62 studies of health status identified were for hip (23) or knee (33) disease. The literature on complications was even more limited with 12 studies of surgical site infection, one for urinary tract infection and none for lower respiratory tract infections. Procedure-specific complications were restricted to one for arthroplasties and three for hernia repair. Despite considerable variation in the findings of studies, some clear patterns emerge, albeit they are largely based on arthroplasty. Patients’ and clinicians’ views of health status generally correlate moderately (0.5-0.6) when both are reporting on the same dimension of health status. Inevitably this is confined to disability, though patients’ and clinicians’ reports of symptoms are also moderately correlated. In contrast, comparisons of different dimensions, such as patients’ reports of disability and clinicians’ reports of impairment, result in poor correlation (0.3). There is huge variation in the way postoperative complications are measured which limits the extent to which an overview can be undertaken. Despite that, moderate to strong correlations have been reported between patients’ and clinicians’ views of complications.

Conclusions

Patients’ views of their level of disability reflect clinicians’ views and can be relied upon to assess this dimension of health status. In addition, patients are the ‘gold standard’ judges of symptoms and quality of life. Given these findings, clinicians, provider managers, commissioners and politicians can be confident that patients’ reports provide an accurate indication of the outcome of elective surgery.

Epidemiological Surveillance of Surgical Site Infection and its Risk Factors in Cardiac Surgery: A Prospective Cohort Study

INTRODUCTION AND OBJECTIVES

Surgical site infection in cardiac surgery is uncommon. The aim of the present study was to examine the incidence of this infection, compare it with national and international data, and evaluate its risk factors.

METHODS

This prospective cohort study included patients who underwent valve surgery or coronary revascularization during a 6-year period. The incidence of surgical site infection was studied. Associations between risk factors and infection were evaluated using odds ratios (OR). The infection rate was compared with Spanish and American data using the standardized infection ratio.

RESULTS

A total of 1557 patients were included. The overall cumulative incidence of infection was 4% (95% confidence interval [95%CI], 3.6%-5.6%), 3.6% in valve surgery (95%CI, 2.5%-4.7%) and 4.3% in coronary revascularization (95%CI, 2.3%-6.3%). Risk factors for surgical site infection in valve surgery were diabetes mellitus (OR=2.8; P<.05) and obesity (OR=6.6; P<.05). Risk factors for surgical site infection in coronary revascularization were diabetes mellitus (OR=2.9; P<.05) and reoperation for bleeding (OR=8.8; P<.05).

CONCLUSIONS

Diabetes mellitus and obesity favor surgical site infection in valve surgery, whereas diabetes mellitus and reoperation for bleeding favor surgical site infection in coronary revascularization. Infection surveillance and control programs permit evaluation and comparison of infection rates in cardiac surgery.

Surgical site infections after hip arthroplasty in Norway, 2005-2011: influence of duration and intensity of postdischarge surveillance

BACKGROUND

Most surgical site infections (SSIs) after hip arthroplasty are detected after a patient is discharged from hospital, making postdischarge surveillance (PDS) an important component in surveillance systems. We investigated how long it was necessary to monitor hip arthroplasty patients for SSIs after hospital discharge and if passive PDS through readmissions could replace active PDS by patient questionnaire in detecting SSIs.

METHODS

We used data from the Norwegian surveillance system from 2005-2011, which has active 1-year PDS, to investigate proportions of SSIs found at different time intervals after surgery and whether these SSIs could have been detected through passive PDS by investigating the proportion of patients with SSIs that were readmitted.

RESULTS

We found that 79% of all SSIs and 82% of deep SSIs were detected after hospital discharge. 95% of deep SSIs were detected within 90 days after surgery. 14% of the deep SSIs were detected beyond 30 days after surgery, and all of these patients were readmitted because of their SSI and thus could have been detected by passive PDS.

CONCLUSIONS

Our data suggest that most deep SSIs are detected within 90 days and that passive PDS beyond 30 days after surgery may replace active PDS without reducing sensitivity.

Surgical wound infection rates in Spain: data summary, January 1997 through June 2012

BACKGROUND

The Indicadores Clínicos de Mejora Continua de la Calidad (INCLIMECC) program was established in Spain in 1997.

METHODS

INCLIMECC is a prospective system of health care-associated infection (HAI) surveillance that collects incidence data in surgical and intensive care unit patients. The protocol is based on the National Healthcare Safety Network (NHSN) surveillance system, formerly known as the National Nosocomial Infection Surveillance (NNIS) system, and uses standard infection definitions from the US Centers for Disease Control and Prevention. Each hospital takes part voluntarily and selects the units and surgical procedures to be surveyed.

RESULTS

This report is a summary of the data collected between January 1997 and June 2012. A total of 370,015 patients were included, and the overall incidence of surgical wound infection (SWI) was 4.51%. SWI rates are provided by NHSN operating procedure category and NNIS risk index category. More than 27% of the patients received inadequate antibiotic prophylaxis, the main reason being unsuitable duration (57.05% of cases).

CONCLUSIONS

Today, the INCLIMECC network includes 64 Spanish hospitals. We believe that an HAI surveillance system with trained personnel external to the surveyed unit is a key component not only in infection control and prevention, but also in a quality improvement system.

Relationship between patients' reports of complications and symptoms, disability and quality of life after surgery

BACKGROUND

Patient-reported complications are increasingly being used to compare the performance of surgical departments. The objectives of this study were to explore the validity of patient-reported complications and to determine their influence on patients' reports of the benefits of surgery (health gain).

METHODS

This was an observational study of patients in England who underwent hip replacement (68,391), knee replacement (77,705), inguinal hernia repair (48,199) or varicose vein surgery (16,535) during 2009-2011. Health gain was assessed with condition-specific measures of symptoms and disability (Oxford Hip Score, Oxford Knee Score, Aberdeen Varicose Vein Questionnaire), health-related quality of life (EQ-5D™ index) and a single item on the success of surgery. Adverse outcomes included four complications, readmission and further surgery.

RESULTS

There was evidence that patient-reported complications were valid. Patients with three or more co-morbid conditions reported more complications, whereas age, sex and socioeconomic status (adjusted for co-morbidity) had little, or no association. Complications were strongly associated with readmission and further surgery. Among patients reporting a complication, the Oxford Hip Score or Oxford Knee Score was about 3 points (or 15 per cent) lower than the value in patients not reporting a complication. The EQ-5D™ score was about 0·07 lower for joint replacement, 0·06 lower for hernia repair and 0·04 lower for varicose vein surgery.

CONCLUSION

Patients' reports of complications can be used for statistical comparisons of surgical departments. If the relationship between complications and health gain is causal, there is scope for improving health gain indicators after surgery by minimizing the risk of a complication.

Infection after primary hip arthroplasty: a comparison of 3 Norwegian health registers

BACKGROUND AND PURPOSE

The aim of the present study was to assess incidence of and risk factors for infection after hip arthroplasty in data from 3 national health registries. We investigated differences in risk patterns between surgical site infection (SSI) and revision due to infection after primary total hip arthroplasty (THA) and hemiarthroplasty (HA).

MATERIALS AND METHODS

This observational study was based on prospective data from 2005-2009 on primary THAs and HAs from the Norwegian Arthroplasty Register (NAR), the Norwegian Hip Fracture Register (NHFR), and the Norwegian Surveillance System for Healthcare-Associated Infections (NOIS). The Norwegian Patient Register (NPR) was used for evaluation of case reporting. Cox regression analyses were performed with revision due to infection as endpoint for data from the NAR and the NHFR, and with SSI as the endpoint for data from the NOIS.

RESULTS

The 1-year incidence of SSI in the NOIS was 3.0% after THA (167/5,540) and 7.3% after HA (103/1,416). The 1-year incidence of revision due to infection was 0.7% for THAs in the NAR (182/24,512) and 1.5% for HAs in the NHFR (128/8,262). Risk factors for SSI after THA were advanced age, ASA class higher than 2, and short duration of surgery. For THA, the risk factors for revision due to infection were male sex, advanced age, ASA class higher than 1, emergency surgery, uncemented fixation, and a National Nosocomial Infection Surveillance (NNIS) risk index of 2 or more. For HAs inserted after fracture, age less than 60 and short duration of surgery were risk factors of revision due to infection.

INTERPRETATION

The incidences of SSI and revision due to infection after primary hip replacements in Norway are similar to those in other countries. There may be differences in risk pattern between SSI and revision due to infection after arthroplasty. The risk patterns for revision due to infection appear to be different for HA and THA.

Outcome of cefazolin prophylaxis for total knee arthroplasty at an institution with high prevalence of methicillin-resistant Staphylococcus aureus infection

OBJECTIVES

The aim of this study was to evaluate the outcome of cefazolin prophylaxis for total knee arthroplasty (TKA) in a hospital with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection.

METHODS

Since July 1, 2006, we have applied a 'care bundle' to TKA to prevent surgical site infection (SSI) without using vancomycin as antimicrobial prophylaxis, in accordance with the 1999 Hospital Infection Control Practices Advisory Committee guidelines. All patients undergoing TKA from July 1, 2006 to September 30, 2009 were enrolled. We reviewed data on SSI collected prospectively as part of routine infection control surveillance.

RESULTS

Of 1323 TKAs, an SSI developed in 14 (1.06%) cases, which is comparable to the percentage obtained in other previous reports. When stratified by the National Nosocomial Infection Surveillance risk index, SSI rates were 0.86% (8/926), 1.30% (5/384), and 7.69% (1/13) in risk categories 0, 1, and 2, respectively. Of 14 SSIs, four (29%) were classified as superficial incisional, two (14%) as deep incisional, and eight (57%) as organ-space SSI.

CONCLUSIONS

Our data suggest that antimicrobial prophylaxis using only cefazolin can maintain low SSI rates if other important infection management measures are employed, even where there is a high prevalence of MRSA infection.

Surgical site infections in primary total hip and knee replacement surgeries, hemiarthroplasties, and osteosyntheses at a Brazilian university hospital

We report a case-control study involving 663 primary orthopedic surgeries with a 12.7% rate of surgical site infections (SSIs). The respective frequencies of superficial incisional, deep incisional, and organ/space infections were 22.2%, 44.5%, and 33.3% for total hip arthroplasties; 66.7%, 33.3%, and 0% for total knee arthroplasties; 0%, 75.0% and 25.0% for hemiarthroplasties; and 44.1%, 35.3%, and 20.6% for osteosyntheses. These rates of SSIs are higher than those reported in previous studies.

Effect of anaesthesia maintained with sevoflurane and propofol on surgical site infection after elective open gastrointestinal surgery

Perioperative increase in oxidative activity in surgical patients reportedly prevents postoperative surgical site infection (SSI). Several clinical studies have shown that oxidative activity under sevoflurane anaesthesia was higher than that under propofol anaesthesia. Therefore, we hypothesised that sevoflurane anaesthesia would discourage SSI compared with propofol anaesthesia. To examine the effect of anaesthesia maintained with sevoflurane and propofol on SSI, a total of 265 consecutive adult patients, with American Society of Anesthesiologists physical status 1-3, who underwent elective open gastrointestinal surgery under general anaesthesia, were surveyed for SSI between January 2007 and December 2008. Sevoflurane or propofol was selected to maintain anaesthesia in 95 and 170 patients, respectively. A propensity score was used for pairwise matching of these patients to avoid selection biases between the two methods of anaesthesia. Propensity matching yielded 84 pairs of patients. We compared standardised infection ratios (SIRs), i.e. the quotient of the number of SSI cases observed and the number of SSI cases expected, calculated using data from the National Nosocomial Infection Surveillance, between sevoflurane and propofol anaesthesia. After propensity matching, SIR after sevoflurane anaesthesia was 1.89 [95% confidence interval (CI): 1.46-2.32], which was significantly lower than after propofol anaesthesia (4.78; 95% CI: 4.30-5.27) (P=0.02). This study suggests that sevoflurane tends to suppress SSI after elective open gastrointestinal surgery compared with propofol.

[Surgical-site infections following varicose vein surgery according to a continuous series of 408 interventions in a teaching hospital]

OBJECTIVE

To determine the incidence of surgical-site infections (SSI) following varicose vein surgery in the vascular surgery ward of a French teaching hospital.

PATIENTS AND METHODS

A prospective surveillance of SSI was conducted during one year, with a 30-day postoperative follow-up. SSI cases were identified by using the definitions of the Centers for Disease Control (CDC, USA). Data acquisition and analysis were performed with the Epi-Info 6.04 software (CDC).

RESULTS

Three quarters of the 408 included interventions were characterized by a NNIS score equal to 0. All patients underwent a hair removing practice before intervention. Hair removing methods were very heterogeneous and often not in accordance with national recommendations (e.g. mechanic shaving for 44.6% of patients). The incidence of SSI was 1.2% (95% confidence interval=[0.2-2.2]). All infections were identified after hospital discharge. Four infected patients out of five presented obesity or excess weight, and two patients had diabetes mellitus. The mean age of infected patients was significantly higher than non-infected ones (70.4 years versus 52.0; p<0.01). All SSI had consequences like rehospitalization, reintervention, or antimicrobial therapy.

CONCLUSION

According to our results, SSI following varicose vein surgery are scarce and mainly concerned high-risk patients. However, in an aim of prevention, it seems necessary to homogenize hair removing methods in this ward.

Rates of surgical site infection after hip replacement as a hospital performance indicator: analysis of data from the English mandatory surveillance system

OBJECTIVE

To describe rates of surgical site infection (SSI) after hip replacement and to use these data to provide a simple mechanism for identifying poorly performing hospitals that takes into account variations in sample size.

DESIGN

Prospective surveillance study.

SETTING

A total of 125 acute care hospitals in England that participated in mandatory SSI surveillance from April 1, 2004 through March 31, 2005.

PATIENTS

Patients who underwent total hip replacement (THR) or hip hemiarthroplasty (HH).

METHODS

A standard data set was collected for all eligible operations at participating hospitals for a minimum of 3 months annually. Defined methods were used to identify SSIs that occurred during the inpatient stay. Data were checked for quality and accuracy, and funnel plots were constructed by plotting the incidence of SSI against the number of operations.

RESULTS

Data were collected on 16,765 THRs and 5,395 HHs. The cumulative SSI incidence rates were 1.26% for THR and 4.06% for HH; the incidence densities were 1.38 SSIs per 1,000 postoperative inpatient days for THR and 2.3 SSIs per 1,000 postoperative inpatient days for HH. The risk of infection associated with revision surgery was significantly higher than that associated with primary surgery (2.7% [95% confidence interval, 2.0%-3.5%] vs. 1.1% [95% confidence interval, 1.0%-1.2%]; P=.003). Rates varied considerably among hospitals. Nineteen hospitals had rates above the 90th percentile. However, the use of funnel plots to adjust for the precision of estimated SSI rates identified 7 hospitals that warranted further investigation, including 2 with crude rates below the 90th percentile.

CONCLUSIONS

Funnel plots of rates of SSI after hip replacement provide a valuable method of presenting hospital performance data, clearly identifying hospitals with unusually high or low rates while adjusting for the precision of the estimated rate. This information can be used to target and support local interventions to reduce the risk of infection.

Study of the efficacy of coated Vicryl plus antibacterial suture in an animal model of orthopedic surgery

PURPOSE

To evaluate the efficacy in vitro and in vivo of a new antibacterial suture, polyglactin 910 suture with triclosan, compared with a traditional braided suture, polyglactin (Vicryl), in a validated animal model of orthopedic infection. Our primary goal was to compare the microbiologic effectiveness of the two sutures. The secondary goal was to evaluate histopathologic signs of an inflammatory response.

METHODS

We used 20 Sprague-Dawley rats. Samples of Staphylococcus epidermidis were diluted to a 0.5 McFarland concentration (100,000 colony-forming units/mL). A surgical steel suture was placed in the spinous process of the rats, and the deep zone of the incision was contaminated bilaterally. Wounds were closed with one of the sutures. After 16 days, the animals were sacrificed, and the surgical wounds were reopened, with cultures being performed of both the zone adjacent to the implant and the deep region of the wound. We also studied the histopathologic features of the tissue adjacent to the implant.

RESULTS

No clinical signs of infection were observed. The culture of the zone adjacent to the implant was positive in nine animals in the polyglactin group vs. three in the polyglactin 910 with triclosan group (p = 0.005). Culture of the deep zone of the wound was positive in ten animals in the polyglactin group vs. six in the polyglactin 910 with triclosan group (p = 0.03). We found predominant polymorphonuclear neutrophil populations in four samples in the polyglactin group vs. two in the polyglactin 910 with triclosan group.

CONCLUSIONS

Under simulated conditions of severe intraoperative contamination, the antibacterial suture reduced the number of positive cultures after surgery by 66.6%. Judging from the available clinical information, its use might contribute to reducing the number of infected implants by 25.8%. Human studies are needed to determine the clinical implications of these results.

Skin and Soft Tissue Infections in Older Adults

Skin and soft tissue infections (SSTIs) are a common cause of morbidity in older patients. Because of changes in skin consistency, immunosenescence, and the presence of underlying skin conditions and comorbid conditions, elderly persons are at high risk for SSTIs. Specific community- and hospital-associated SSTIs are reviewed in this article with particular emphasis on the epidemiology, prevention, risk factors, and treatment of SSTIs in older patients.

Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis?

Post-discharge surgical infection surveillance by patients remains an integral part of many infection control programmes despite proven unreliability. We attempted to improve the validity of patient recognition of signs and symptoms of wound infection and post-discharge postal questionnaire responses through specific education prior to discharge. In total, 588 patients were studied after random assignment into two intervention groups, one of which received relevant education. Both groups were followed for four weeks post-operatively, with features of infection assessed weekly by experienced infection control nurses (ICNs) and by patient responses to routine postal questionnaires. Those patients who received education demonstrated a significantly poorer correlation with ICN diagnosis compared to the non-educated group (Kappa 0.69 and 0.81 respectively, P=0.05). Both patient groups achieved the same sensitivity for recall (83.3%), with high specificity demonstrated by both groups [educated (93.7%); non-educated (98.1%)]. The positive predictive value was 65.2% for the educated group and 83.3% for the non-educated patient group. When infected wounds identified by patients were examined for the proportion that were overdiagnosed, the excess of SSI identified by the educated patient group was 44.4% and by the non-educated group 16.7%. These results suggest that pre-discharge education causes patients to overdiagnose clinical features of wound infection and fails to improve the validity of diagnosis. This outcome further questions the value of post-discharge infection rates obtained by patient self-assessment as a measure of quality of performance.

Surgical site infection surveillance for neurosurgical procedures: a comparison of passive surveillance by surgeons to active surveillance by infection control professionals

ISSUE

Surveillance methods for surgical site infections (SSIs) range from patient self-report to active surveillance by infection control professionals (ICPs). Surgeon questionnaires surveying SSIs are typically suboptimal due to bias, lack of standardized criteria to diagnose infection, and poor response rate. Although concurrent surveillance of SSIs by ICPs at our medical center documented an incidence of 2.2 SSIs per 100 procedures, the neurosurgeons perceived a much higher rate of SSIs.

PROJECT

The neurosurgeons provided a list of patients they had clinically identified with SSIs over a 7 month period. This list was compared with a line listing of SSIs independently identified by ICPs via concurrent surveillance utilizing the Centers for Disease Control and Prevention (CDC) definitions.

RESULTS

A total of 766 procedures were performed. Active surveillance by ICPs detected 17 infections (2.2/100 procedures). Of the 14 cases identified by the neurosurgeons, 3 did not meet the CDC definition of a nosocomial infection. The ICPs identified 6 SSIs not documented by the neurosurgeons. Compared to active surveillance by ICPs, the sensitivity and specificity of the neurosurgeon's identification of SSIs was 64% and 99.6%, respectively. The positive predictive value was 78.6% and the negative predictive value was 99.2%.

LESSONS LEARNED

An active surveillance program is necessary for accurate identification of SSIs. The primary problem with passive surveillance by surgeons is failure to capture cases; surgeons missed 36% of cases compared to active surveillance by ICPs.