Telephone call contact for post-discharge surveillance of surgical site infections. A pilot, methodological study

Has network meta-analysis resolved the controversies related to bowel preparation in elective colorectal surgery?

AIM

There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs.

METHOD

A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines.

RESULTS

Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options.

CONCLUSION

While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs.

Diagnostic accuracy of telemedicine for detection of surgical site infection: a systematic review and meta-analysis

The Sars-CoV-2 pandemic catalysed integration of telemedicine worldwide. This systematic review assesses it’s accuracy for diagnosis of Surgical Site Infection (SSI). Databases were searched for telemedicine and wound infection studies. All types of studies were included, only paired designs were taken to meta-analysis. QUADAS-2 assessed methodological quality. 1400 titles and abstracts were screened, 61 full text reports were assessed for eligibility and 17 studies were included in meta-analysis, mean age was 47.1 ± 13.3 years. Summary sensitivity and specificity was 87.8% (95% CI, 68.4–96.1) and 96.8% (95% CI 93.5–98.4) respectively. The overall SSI rate was 5.6%. Photograph methods had lower sensitivity and specificity at 63.9% (95% CI 30.4–87.8) and 92.6% (95% CI, 89.9–94.5). Telemedicine is highly specific for SSI diagnosis is highly specific, giving rise to great potential for utilisation excluding SSI. Further work is needed to investigate feasibility telemedicine in the elderly population group.

Impact of Incisional Surgical Site Infections on Quality of Life and Patient Satisfaction after General Surgery: A Case Controlled Study

Background: Most incisional surgical site infections (ISSI) are now diagnosed after discharge from hospital. In this context, it is important to document the impact ISSI has on our patients. Patients and Methods: Our surgical department sent a validated questionnaire to patients after they had been discharged. This documented incision problems, the 36-Item Short Form Health (SF-36) qualify of life questionnaire, and a patient satisfaction survey (PSS). We retrospectively reviewed records for 115 patients with an ISSI and 115 matched controls with no documented complications. Patient demographics and outcomes were collected. Differences in physical component summary (PCS) score and mental component summary (MCS) score and the PSS score were compared. Results: A majority (87%) of ISSIs were diagnosed after discharge from hospital. There were no differences in demographics, the American Society of Anaesthesiologists grade, or length of stay (LOS) between groups. Two months after surgery, ISSI was associated with lower post-operative SF-36 scores. The PCS was 42.9 (95% confidence interval [CI], 41.3-44.8) for ISSI cases and 47.0 (95% CI, 45.1-48.7) for controls (p ≤ 0.001). The MCS was 45.8 (95% CI, 43.7-47.9) and 50.2 (95% CI, 48.0-52.3), respectively (p = 0.01). Patients had less vitality, increased pain, and a reduction in physical activities and roles. The PSS score was 82.5 (95% CI, 79.6-85.4) in the control group and 74.1 (95% CI, 71.1-77.0) in the ISSI group (p < 0.001). Patients with ISSI reported worse satisfaction ratings with the quality of information received (p = 0.005) and their satisfaction with surgery (p < 0.001). Conclusions: Incisional surgical site infection was correlated with lower quality of life and PSS scores for up to two months after surgery. Prospective studies with pre-operative and post-operative quality of life are required to confirm causality.

A randomised trial of caesarean wound coverage: exposed versus dressed

OBJECTIVE

To evaluate the superficial surgical site infection (SSI) rate to 28 days and patient satisfaction with wound coverage management when their transverse suprapubic caesarean wound is left exposed compared with dressed after skin closure.

DESIGN

Randomised trial.

SETTING

University Hospital, Malaysia: April 2016-October 2016.

POPULATION

331 women delivered by caesarean section.

METHOD

Participants were randomised to leaving their wound entirely exposed (n = 165) or dressed (n = 166) with a low adhesive dressing (next day removal).

MAIN OUTCOME MEASURES

Primary outcomes were superficial SSI rate (assessed by provider inspection up to hospital discharge and telephone questionnaires on days 14 and 28) and patient satisfaction with wound coverage management before hospital discharge.

RESULTS

The superficial SSI rates were 2/153 (1.3%) versus 5/157 (3.2%) (relative risk [RR] 0.4, 95% CI 0.1-2.1; P = 0.45) and patient satisfaction with wound management was 7 [5-8] versus 7 [5-8] (P = 0.81) in exposed compared with dressed study groups, respectively. In the wound-exposed patients, stated preference for wound exposure significantly increased from 35.5 to 57.5%, whereas in the wound-dressed patients, the stated preference for a dressed wound fell from 48.5 to 34.4% when assessed at recruitment (pre-randomisation) to day 28. There were no significant differences in inpatient additional dressing or gauze use for wound care, post-hospital discharge self-reported wound issues of infection, antibiotics, redness and inflammation, swollen, painful, and fluid leakage to day 28 across trial groups.

CONCLUSION

The trial is underpowered as SSI rates were lower than expected. Nevertheless, leaving caesarean wounds exposed does not appear to have detrimental effects, provided patient counselling to manage expectations is undertaken.

TWEETABLE ABSTRACT

An exposed compared with a dressed caesarean wound has a similar superficial surgical site infection rate, patient satisfaction and appearance.

Is telephone follow-up really effective in early diagnosis of inflammatory complications after tooth extraction?

BACKGROUND

To establish whether telephone follow-up is really able to intercept post-extraction complications and to evaluate the degree of patient satisfaction with this kind of post-surgical monitoring.

MATERIAL AND METHODS

six hundred and thirty-eight patients were enrolled and randomly assigned to a test or control group. Test group patients were monitored by telephone follow-up 24 and 72 hours after surgery to investigate the presence of local symptoms that are frequently associated with surgical wound infection and inflammation. Both test and control group patients were examined 7 days at suture removal. Patients with systemic diseases, those in which intra-operative accidents occurred during surgery and those for whom extraction suture was not required, were excluded.

RESULTS

At least one complication among alveolar osteitis, alveolar inflammation, alveolar infection and dehiscence involved 15.70% of the patients in the test group and 30.70% of the patients in the control group and telephone follow-up proved to be useful in early identification of anomalies in the post-extraction wound healing process. Comparable results were recorded in all extraction subgroups divided according to the type (surgical and non-surgical) and the number (single and multiple) of extractions performed in the same session. Telephone follow-up showed an 8.60 ± 1.17 (0 to 10 score scale) average acceptance. All cases of alveolar osteitis and infection occurred in patients who underwent antibiotic prophylaxis.

CONCLUSIONS

Telephone follow-up seems to allow early detection of any possible wound healing complications, it is widely accepted by patients and it could therefore be considered a valid method for wound healing monitoring after tooth extractions, due to its effectiveness, feasibility and low costs.

Postdischarge surveillance of surgical site infections using telephone calls and a follow-up card in a resource-limited setting

The use of a follow-up card and telephone calls appeared to be an efficient modality for postdischarge surveillance of surgical site infections (SSIs) in Cambodia. One hundred and sixty-one patients were given a follow-up card and asked to present it to any healthcare practitioner they visited during the 30 days following their surgery. Patients were subsequently telephoned to collect information. After discharge, 87% of the patients provided follow-up data. Of these, 25 patients with no SSIs detected during hospitalization reported that 'white liquid had discharged from the surgical wound'; among them, nine cases of purulent drainage were reported by a practitioner.

Multidrug-resistant surgical site infections in a humanitarian surgery project

The epidemiology of surgical site infections (SSIs) in surgical programmes in sub-Saharan Africa is inadequately described. We reviewed deep and organ-space SSIs occurring within a trauma project that had a high-quality microbiology partnership and active follow-up. Included patients underwent orthopaedic surgery in Teme Hospital (Port Harcourt, Nigeria) for trauma and subsequently developed a SSI requiring debridement and microbiological sampling. Data were collected from structured chart reviews and programmatic databases for 103 patients with suspected SSI [79% male, median age 30 years, interquartile range (IQR) 24-37]. SSIs were commonly detected post-discharge with 58% presenting >28 days after surgery. The most common pathogens were: Staphylococcus aureus (34%), Pseudomonas aeruginosa (16%) and Enterobacter cloacae (11%). Thirty-three (32%) of infections were caused by a multidrug-resistant (MDR) pathogen, including 15 patients with methicillin-resistant S. aureus. Antibiotics were initiated empirically for 43% of patients and after culture and sensitivity report in 32%. The median number of additional surgeries performed in patients with SSI was 5 (IQR 2-6), one patient died (1%), and amputation was performed or recommended in three patients. Our findings suggest the need for active long-term monitoring of SSIs, particularly those associated with MDR organisms, resulting in increased costs for readmission surgery and treatment with late-generation antibiotics.

Incidence and significance of postoperative complications occurring between discharge and 30 days: a prospective cohort study

BACKGROUND

Accurate documentation of complications is fundamental to clinical audit and research. While it is established that accurate diagnosis of surgical site infection (SSI) requires follow-up for 30 days; for other complications, there are minimal data quantifying their importance between discharge and 30 days.

METHODS

In this prospective cohort study, inpatients undergoing general or vascular surgery were reviewed daily for complications by the medical team and a research fellow. A standardized telephone questionnaire was performed 30 days following surgery. All complications were documented and classified according to severity.

RESULTS

A total of 237 of 388 patients who completed the telephone survey developed a complication, including 77 who developed a complication for the first time after discharge from hospital. Overall 135 (33%) of a total of 405 complications were identified after discharge. These complications included 36 of 63 (57%) SSI, 6 of 12 small bowel obstructions, and three of four major thromboembolic events and a number of space SSI, urinary infections, functional gastrointestinal problems, and pain management problems. Cardiac, respiratory, and neurologic complications were mainly diagnosed in hospital. Of the 135 "postdischarge" complications, 89 were managed in the community and 46 (34%) resulted in admission to hospital, including seven which required a major intervention. There was one death.

CONCLUSIONS

One-third of complications occurred after discharge, and one-third of these resulted in readmission to hospital. Research and audit based on inpatient data alone significantly underestimates morbidity rates. Discharge planning should include contingency plans for managing problems commonly diagnosed after discharge form hospital.

Surgical-Site Infections Following Cesarean Section in an Estonian University Hospital: Postdischarge Surveillance and analysis of Risk Factors

Objectives:

To evaluate a multi-method approach to postdischarge surveillance of surgical-site infections (SSIs) and to identify infection rates and risk factors associated with SSI following cesarean section.

Design:

Cross-sectional survey.

Setting:

Academic tertiary-care obstetric and gynecology center with 54 beds.

Patients:

All women who delivered by cesarean section in Tartu University Women's Clinic during 2002.

Methods:

Infections were identified during hospital stay or by postdischarge survey using a combination of telephone calls, healthcare worker questionnaire, and outpatient medical records review. SSI was diagnosed according to the criteria of the Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System.

Results:

The multi-method approach gave a follow-up rate of 94.8%. Of 305 patients, 19 (6.2%; 95% confidence interval [CI95)], 3.8-9.6) had SSIs. Forty-two percent of these SSIs were detected during postdischarge surveillance. We found three variables associated with increased risk for developing SSI: internal fetal monitoring (odds ratio [OR], 16.6; CI95, 2.2-125.8; P = .007), chorioamnionitis (OR, 8.8; CI95, 1.1-69.6; P = .04), and surgical wound classes III and IV (OR, 3.8; CI95, 1.2-11.8; P=.02).

Conclusions:

The high response rate validated the effectiveness of this kind of surveillance method and was most suitable in current circumstances. A challenge exists to decrease the frequency of internal fetal monitoring and to treat chorioamnionitis as soon as possible (Infect Control Hosp Epidemiol 2005;26:449-454).

Use of Medicare Claims to Rank Hospitals by Surgical Site Infection Risk following Coronary Artery Bypass Graft Surgery

Objective.

To evaluate whether longitudinal insurer claims data allow reliable identification of elevated hospital surgical site infection (SSI) rates.

Design.

We conducted a retrospective cohort study of Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) in US hospitals performing at least 80 procedures in 2005. Hospitals were assigned to deciles by using case mix–adjusted probabilities of having an SSI-related inpatient or outpatient claim code within 60 days of surgery. We then reviewed medical records of randomly selected patients to assess whether chart-confirmed SSI risk was higher in hospitals in the worst deciles compared with the best deciles.

Participants.

Fee-for-service Medicare beneficiaries who underwent CABG in these hospitals in 2005.

Results.

We evaluated 114,673 patients who underwent CABG in 671 hospitals. In the best decile, 7.8% (958/12,307) of patients had an SSI-related code, compared with 24.8% (2,747/11,068) in the worst decile (P<.001). Medical record review confirmed SSI in 40% (388/980) of those with SSI-related codes. In the best decile, the chart-confirmed annual SSI rate was 3.2%, compared with 9.4% in the worst decile, with an adjusted odds ratio of SSI of 2.7 (confidence interval, 2.2–3.3; P<.001) for CABG performed in a worst-decile hospital compared with a best-decile hospital.

Conclusions.

Claims data can identify groups of hospitals with unusually high or low post-CABG SSI rates. Assessment of claims is more reproducible and efficient than current surveillance methods. This example of secondary use of routinely recorded electronic health information to assess quality of care can identify hospitals that may benefit from prevention programs.

[Implementation of a post-discharge surgical site infection system in herniorrhaphy and mastectomy procedures]

INTRODUCTION

Monitoring surgical site infection (SSI) performed during hospitalization can underestimate its rates due to the shortening in hospital stay. The aim of this study was to determine the actual rates of SSI using a post-discharge monitoring system.

METHODS

All patients who underwent herniorraphy or mastectomy in the Hospital Universitario Ramón y Cajal from 1 January 2011 to 31 December 2011 were included. SSI data were collected prospectively according to the continuous quality improvement indicators (Indicadores Clinicos de Mejora Continua de la Calidad [INCLIMECC]) monitoring system. Post-discharge follow-up was conducted by telephone survey.

RESULTS

A total of 409patients were included in the study, of whom 299 underwent a herniorraphy procedure, and 110 underwent a mastectomy procedure. For herniorrhaphy, the SSI rate increased from 6.02% to 7.6% (the post-discharge survey detected 21.7% of SSI). For mastectomy, the SSI rate increased from 1.8% to 3.6% (the post-discharge survey detected 50% of SSI).

CONCLUSIONS

Post-discharge monitoring showed an increased detection of SSI incidence. Post-discharge monitoring is useful to analyze the real trend of SSI, and evaluate improvement actions. Post-discharge follow-up methods need to standardised.

Postdischarge surveillance following delivery: the incidence of infections and associated factors

BACKGROUND

To assess the effectiveness of a postdischarge surveillance system to reveal cases of postpartum infections that could be missed by the current in-hospital routine surveillance and to identify predictors of postpartum infections.

METHODS

The prospective surveillance included obstetrics patients. The information recorded included sociodemographic characteristics, infection-predisposing conditions, documentation of extrinsic risk factors, variables related to pregnancy and delivery, and variables related to each patient's newborn. A telephone interview on Day 30 after hospital discharge was performed to retrieve information related to signs and symptoms of infection.

RESULTS

One thousand seven hundred five patients agreed to participate for a response rate of 93%. One hundred forty-nine (8.9%) patients contacted by telephone reported at least 1 episode of infection within 30 days of discharge. There were 24 infections occurring during hospitalization, representing only 16.1% of all infections. There was an increased risk of postpartum infections in women with complications during labor, in those who had a caesarean delivery, and in those who reported alcohol consumption during pregnancy.

CONCLUSION

Our study demonstrated the need for implementing postdischarge surveillance programs for obstetrics patients that also identify infections following vaginal delivery. Postdischarge surveillance by telephone contact proved to be a feasible and effective method.

Inter-hospital comparison of rates of surgical site infection following caesarean section delivery: evaluation of a multicentre surveillance study

BACKGROUND

Short postoperative stays following caesarean section delivery make it difficult to assess accurately the risk of surgical site infection (SSI). Methods of case-finding that minimize variation are required to support effective surveillance systems, especially where used for benchmarking.

AIM

To evaluate the efficacy of case-finding methods for SSI following caesarean delivery and their utility in establishing benchmark rates of SSI.

METHODS

Hospitals conducted surveillance over one or two 13-week periods. Patients were reviewed during their inpatient stay, post partum by community midwives and via patient questionnaire at 30 days post delivery. To estimate the reliability of case-finding methods, case-note reviews were undertaken in a random sample of four hospitals.

FINDINGS

A total of 404 SSIs were detected in 4107 caesarean deliveries from 14 hospitals. The median time to SSI was 10 days, 66% were detected in-hospital or by community midwives, and an additional 34% were patient-reported. The rate of SSI was 9.8% but the proportion of patients followed up varied significantly between centres. The estimated sensitivity and specificity of case-finding was 91.4% [95% confidence interval (CI): 53.4-98.4] and 98.6% (95% CI: 98.4-98.8), the positive predictive value 91.0% (95% CI: 82.4-96.1) and negative predictive value 98.6% (95% CI: 93.9-99.5).

CONCLUSIONS

Combined case ascertainment methods are a feasible way to achieve active post-discharge surveillance and had high negative and positive predictive values. Additional SSIs can be detected by patient questionnaires but rates of SSI were strongly influenced by variation in intensity of both healthcare worker- and patient-based case-finding. This factor must be taken into account when comparing or benchmarking rates of SSI.

Surveillance of surgical site infection post vasectomy

The aim of this study was to determine the incidence of surgical site infection (SSI) after vasectomy and to identify associated patient and perioperative risk factors, including the operating room environment (non-ventilated treatment room or ventilated operating theatre). This study used an active 30-day surveillance follow-up programme with telephone interviews and home visits. Patients were recruited over an 18 month period. Demographics, patient details and perioperative procedures were documented on the day of surgery. Patients were telephoned 10 and 30 days post procedure. Of 1,155 patients enrolled, 994 (86%) completed the full 30-day follow-up. Of these, 25 (2.5%) developed an SSI. The mean number of days until presentation with an SSI was 13. No statistically significant difference was found in rates of SSI when vasectomies were undertaken in either ventilated operating theatres or non-ventilated treatment rooms.

Surgical site infection: the principles and practice of surveillance. Part 1: Key concepts in the methodology of SSI surveillance

urgical site infections (SSI) account for a major proportion of healthcare associated infections (HCAI) yet many hospitals capture little data on the risk of SSI in patients undergoing surgery and therefore have little assurance about the quality of infection prevention in their operating departments. This paper is the first part of a two part series that will examine the principles and practice of surveillance of SSI. Part 2 will examine the analysis of SSI data and the use of the results to change practice. This paper reviews the principles that underpin SSI surveillance methodology, key concepts that affect the accuracy of data capture systems and strategies for addressing them, including risk factors and active case finding systems to ensure detection of SSI, including those that develop after discharge from hospital.

Effect of interventions in reducing the rate of infection after cesarean delivery

BACKGROUND

Post-cesarean delivery (CD) surgical site infections can cause considerable maternal morbidity. We aimed to estimate the efficacy of a medical personnel education program in aseptic and scrub techniques on the rate of infectious morbidity after CD.

METHODS

A prospective, 2-period cohort intervention study was performed at a single institution. The first era, which included all CDs performed between September 2006 and August 2007, was used to obtain baseline infection rates. During this period, prophylactic antibiotics were given only to women undergoing elective CD. In era 2, July 2009 through June 2010, prophylactic antibiotics were given to all women. In addition, medical personnel underwent an education program, refresher course, and retraining in aseptic and scrub techniques. The study's primary outcome included any infectious morbidity related to the CD within 30 days from the operation.

RESULTS

The 1,616 CDs analyzed included 751 performed in era 1 and 865 performed in era 2. The incidence of any infectious morbidity dropped from 6.4% in era 1 to 2.5% in era 2 (P = .001). The incidence of any infectious morbidity in women undergoing elective CD fell from 5.3% to 0.9% (P = .001). Among women undergoing nonelective CD, the difference between the first and second eras was not statistically significant (7.5% vs. 4.5%; P = .09). However, the rate of incisional surgical site infection fell significantly, from 4% in era 1 to 1.5% in era 2 (P = .05).

CONCLUSIONS

The interventions implemented at our institution led to a considerable decline in post-CD infectious morbidity.

Three questions to screen for postdischarge surgical site infections

In-hospital surveillance of surgical site infections (SSI) was conducted on 599 patients in a German university hospital. On a subgroup of 342 patients, SSI was assessed after discharge from hospital based on data of a questionnaire and telephone interviews. Postdischarge surveillance revealed substantially higher infection rates than in-hospital surveillance. From assessment of single questionnaire items, a model of a 3-item questionnaire for surveillance of SSI is proposed.

Surgical-site infection surveillance in general surgery: a critical issue

This prospective study assessed the Surgical Site Infection (SSI) rates in General Surgery and the microorganisms isolated. From January 2000 to October 2000, 898 patients were enrolled and electively operated in a General Surgery Clinic in Athens, Greece. Pre-coded questionnaires were used. The diagnosis and surveillance of SSIs was made by the surgeon-investigator who interviewed the patients. Patients were monitored during hospitalization and post-discharge for 30 days. Overall, 402 patients underwent a clean and 496 patients underwent a clean-contaminated operation. A total of 17 SSIs (4.2%) were observed in clean and 64 SSIs (12.9%) in clean-contaminated operations. Microorganisms were isolated in 36 of 65 (55%) of cases that microbiological evaluation was performed. Staphylococcus aureus was the commonest microorganism isolated, followed by Escherichia coli and Pseudomonas aeruginosa. SSI rates were higher than expected and most SSIs, 43 of 81 (53.1%), were diagnosed post-operatively. Post-discharge surveillance of SSIs remains a critical issue. Health care professionals, especially surgeons, should participate in surveillance networks and be aware of the results so to take appropriate action.

Surgical site infections in orthopedic patients: prospective cohort study

AIM

To estimate the incidence rate and risk factors of surgical site infections in the orthopedic wards in a major teaching hospital in Serbia.

METHODS

A 6-month prospective cohort study, with 30 days of patient follow-up after surgery, was conducted at the teaching hospital in Belgrade. We collected patients' basic demographic data and data on underlying disease status, surgical procedures, preoperative preparation of patients, and antibiotic prophylaxis. The National Nosocomial Infections Surveillance (NNIS) risk index was computed for each patient. Descriptive and logistic regression analyses were performed to determine risk factors for surgical site infections.

RESULTS

Assessment of 277 patients after operation revealed surgical site infection in 63 patients. In 3 (4.8%) of them, surgical site infections were detected after hospital discharge. The overall incidence rate of surgical site infections was 22.7% (95% confidence interval [95% CI], 17.5-29.1). The incidence increased from 13.2% in clean wounds to 70.0% in dirty wounds. The rates of surgical site infection for the NNIS risk index classes 0 to 3 were 8.1% (13 of 161), 36.4% (32 of 88), 63.0% (17 of 27), and 100% (1 of 1) (P<0.001; chi2 test). Multivariate logistic regression analysis identified the following independent risk factors for surgical site infections: greater number of persons in the operating room (odds ratio [OR], 1.28; 95% CI, 1.02-1.60), contaminated or dirty wounds (OR, 12.09; 95% CI, 5.56-26.28), and American Society of Anesthesiologists' (ASA) score >2 (OR, 3.47; 95% CI, 1.51-7.95). In patients who were shaved with a razor, the period of 12 or more hours between shaving and intervention was also an independent risk factor (OR, 2.77; 95% CI, 1.22-6.28).

CONCLUSION

There is a high incidence of surgical site infections in orthopedic patients in Serbia in comparison with developed countries and some developing countries. Points for intervention could be reduction of personnel during surgery, better treatment of wounds, decreasing ASA score, and reduction of the time between surgical site shaving and the intervention.

Nine-year downward trends in surgical site infection rate in southeast France (1995–2003)

The aim of this study was to estimate temporal trends in the incidence of surgical site infection (SSI) using a large SSI surveillance network in southeast France from 1995 to 2003. Data were analysed from 187 surgical wards that had participated in the network for at least two years. The change in SSI rate over time was modelled using a hierarchical logistic regression model with patients clustered within surgical wards. Of the 200 207 patients selected, 3786 (1.9%) had an SSI. The nine-year trend in SSI rate estimated by an odds ratio of 0.95 (95% confidence interval 0.93-0.97) was interpreted as a 5% decrease in SSI rate per year. This decrease was constant over the study period and was observed for almost all of the different types of surgical operations (orthopaedic, gastrointestinal, urology, etc). Overall SSI rates were reduced by 45% over a period of nine years. This trend was maintained even when taking into account the heterogeneity of the surgical wards and the diversity of patient demographics over time. From this, the 5% decrease per year can be reasonably interpreted as a result of preventive measures taken by surgical wards to reduce SSIs.

Post-discharge surgical site infection surveillance by automated telephony

Surgical site infection (SSI) is an important outcome indicator after surgery and is part of a national programme of surveillance in Scotland. Post-discharge surveillance has important cost implications for both primary and acute areas of the NHS and it is therefore important to establish a robust method to obtain these data. This study used an automated telephony system to gain information on SSI developing post-discharge. The patients included were those who had inpatient surveillance carried out following hip and knee replacements, and cardiac surgery. A recorded message was used to ask the patient questions concerning the state of their wound. These questions were answered by pressing numbers on their phone. The study population was 104 and there were 18 patients who thought they had a wound infection but after clarification only nine patients suffered a post-discharge SSI. The number of patients who responded with at least one call to the system was 62. Although this pilot study was carried out with small numbers, it was felt that with certain refinements it should continue to be used for post-discharge surgical site surveillance of infection.

Developing algorithms for healthcare insurers to systematically monitor surgical site infection rates

BACKGROUND

Claims data provide rapid indicators of SSIs for coronary artery bypass surgery and have been shown to successfully rank hospitals by SSI rates. We now operationalize this method for use by payers without transfer of protected health information, or any insurer data, to external analytic centers.

RESULTS

We performed a descriptive study testing the operationalization of software for payers to routinely assess surgical infection rates among hospitals where enrollees receive cardiac procedures. We developed five SAS programs and a user manual for direct use by health plans and payers. The manual and programs were refined following provision to two national insurers who applied the programs to claims databases, following instructions on data preparation, data validation, analysis, and verification and interpretation of program output. A final set of programs and user manual successfully guided health plan programmer analysts to apply SSI algorithms to claims databases. Validation steps identified common problems such as incomplete preparation of data, missing data, insufficient sample size, and other issues that might result in program failure. Several user prompts enabled health plans to select time windows, strata such as insurance type, and the threshold number of procedures performed by a hospital before inclusion in regression models assessing relative SSI rates among hospitals. No health plan data was transferred to outside entities. Programs, on default settings, provided descriptive tables of SSI indicators stratified by hospital, insurer type, SSI indicator (inpatient, outpatient, antibiotic), and six-month period. Regression models provided rankings of hospital SSI indicator rates by quartiles, adjusted for comorbidities. Programs are publicly available without charge.

CONCLUSION

We describe a free, user-friendly software package that enables payers to routinely assess and identify hospitals with potentially high SSI rates complicating cardiac procedures.

Procedure-specific surgical site infection rates and postdischarge surveillance in Scotland

OBJECTIVE

To investigate the impact of postdischarge surveillance (PDS) on surgical-site infection (SSI) rates for selected surgical procedures in acute care hospitals in Scotland.

DESIGN

Prospective surveillance of SSI after selected surgical procedures.

SETTING

The Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP), which is based on the methodology of the Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance system (NNIS). Thirty-two of 46 acute care hospitals throughout Scotland contributed data to SSHAIP for this study.

METHODS

Data were from 21,710 operations that took place between April 1, 2002, and June 30, 2004; nine categories of surgical procedures were analyzed. CDC NNIS system definitions and methods were used for SSI PDS. PDS is a voluntary component of the mandatory SSI surveillance program in Scotland. PDS was categorized as none, passive, active without direct observation, and active with direct observation.

RESULTS

From our study information, PDS data were available for 12,885 operations (59%). A total of 2,793 procedures (13%) were associated with passive PDS and 10,092 (46%) with active PDS. The SSI rate among the 8,825 operations with no PDS was 2.61% (95% confidence interval [CI], 2.3%-3.0%), which was significantly lower than the SSI rate found among the 12,885 operations for which PDS was performed (6.34% [95% CI, 5.9%-6.8%]). For breast surgery, cesarean section, hip replacement, and abdominal hysterectomy, the rate of SSI when PDS was performed was significantly higher than that when PDS was not performed (P<.01 for each procedure). No differences in SSI rates were found for surgery to repair fractured neck of the femur or for knee replacement. SSI rates were examined according to procedure type, performance of PDS, and NNIS risk index; rates of SSI increased with NNIS risk index within procedure group and PDS group. Logistic regression analyses confirmed that procedure type, performance of PDS, and NNIS risk index were all statistically independent predictors of report of an SSI (P<.05).

CONCLUSIONS

This Scottish national data set incorporates a substantial amount of PDS data. We recommend a procedure-specific approach to PDS, with direct observation of patients after breast surgery, cesarean section, and hysterectomy, for which the length of stay is typically short. Readmission surveillance may be adequate to detect most SSIs after orthopedic surgery or vascular surgery, for which the length of stay is typically longer.

[Incidence of surgical site infections in the departments of orthopedics and traumatology]

BACKGROUND/AIM

Besides infections of urinary tract and pneumonias, as well as blood infections, surgical site infections (SSI) represent one of the most common localization of hospital infections. The aim of this study was to determine the incidence of SSI in the departments of orthopedics and traumatology as well as the SSI incidence in relation to the ASA score, surgical site contamination class and NNIS index.

METHODS

A prospective cohort study followed daily all the surgical patients hospitalized over 48 hours in the Institute for Orthopedic Surgery and Traumatology, Clinical Center of Serbia, as well as 30 days after the discharge, during the period betwen February 1 to July 31, 2002. The patients were examined and their diagnoses made according to the definition of hospital infections, i.e. upon clinical and/or laboratory analyses, using concurrently the ASA score, surgical site contamination class and NNIS index.

RESULTS

Out of 227 surgical patients, 60 were diagnosed with SSI during their hospitalization, while 3 of the patients developed SSI after the discharge. The incidence of SSI was 22.7% (95% CI = 17.8-27.6). In the patients with good health condition, i.e. ASA < or = 2, the incidence of SSI was 18.3% (43/235) and in those with ASA > 2, it was 47.6% (20/42) (chi2 = 17.4; p < 0.001). The incidence of SSI was 13.5% (25/185) in the clean wounds, 11.6% (5/43) in purely contaminated, while it was much higher in the contaminated 65.5%; (19/29) and soiled 70.0%; (14/20) wounds (chi2 = 67.6; p < 0.001). The incidence of SSI in relation to NNIS was 8.1% (13/161) in the patients with score 0, then 36.4% (32/88) in the patients with score 1, and 64.3% (18/28) in the patients with the scores 2 and 3 (chi2 = 57.3; p < 0.001). The patients with SSI stayed in the departments of orthopedics and traumatology approximately 1.8 times longer than the patients without SSI (t = 5.3; DF = 275; p < 0.0019.

CONCLUSION

It is important to emphasize the need for constant epidemiological surveillance of SSI and the implementation of preventive measures in Serbia.

Reduction in wound infection rates by wound surveillance with postdischarge follow-up and feedback

Background

Surgical wound surveillance with postdischarge follow-up is rarely done in the UK as it is seen as expensive. The aim of this study was to determine whether employing a dedicated team was effective and reduced costs.

Methods

Infection data were collected prospectively with postdischarge follow-up at 2–3 months, and fed back to surgeons. Wound infection was defined using both ASEPSIS wound scoring and criteria of the US Centers for Disease Control (CDC) definitions.

Results

Over 4 years, 15 548 patient episodes were included. Postdischarge surveillance data were available for 79·9 per cent of the 15 154 records of patients who survived. There was a significant reduction in the rate of wound infection between the first and fourth years by ASEPSIS and CDC definitions: odds ratio 0·77 (95 per cent confidence interval (c.i.) 0·64 to 0·92) and 0·69 (95 per cent c.i. 0·57 to 0·83), respectively. The proportion of infections fell significantly in orthopaedic, cardiac and thoracic surgery. The annual budget for wound surveillance was £91 600. Changes in infection rates contributed £347 491 to the reduction in cost among the patients surveyed.

Conclusion

Wound surveillance was associated with a reduction in rates of wound infection within 4 years. The cost reduction as a result of fewer infections exceeded the cost of surveillance after 2 years.

[Nosocomial infections in the departments of orthopedics and traumatology]

AIM

To determine the incidence and the localization of nosocomial infections (NI) in the departments of orthopedics and traumatology.

METHODS

A prospective cohort study carried out between February 1 and July 31, 2002 included all of the surgical patients who were hospitalized longer than 48 hours, as well as 30 days after the discharge. The patients were examined and their diagnoses made according to the definition of NI, that was based on the clinical and/or laboratory findings.

RESULTS

Out of 277 hospitalized patients, 78 had a total of 91 NIs. Sixty-seven (85.8%) of the patients had 1 registered NI each, 9 (11.6%) of the patient had 2 NIs each, while only the 2 (2.6%) were with 3 NIs. The incidence of the patients with HAI was 28.2% (95% IP = 22.9-33.5), while the incidence of HAI was 32.8%. The patients who developed a NI were hospitalized almost twice as long as the patients who did not (t test = 6.0, DF = 275, p < 0.001). In regard to the duration of hospitalization, the incidence of NI was 12.3 per 1000 patient-hospital days. The patients operated on most frequently had the surgical-site infections (69.2%). Of 63 infections of the surgical site, 3 patients (4.8%) were diagnosed as having the NI at that localization following the discharge, and then the urinary tract infections, 25.3% (23/91), and sepsis, 5.5% (5/91).

CONCLUSION

Epidemiological surveillance was the first step towards the prevention and the eradication of NI. The results of this study could be of use in planning of the adequate measures for the prevention of NI in the departments of orthopedic surgery.

Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair

Background

Severe chronic pain is a long-term problem that may occur after inguinal hernia repair. The aim of this randomized study was to compare pain of any severity at 12 months after inguinal hernia repair with a partially absorbable lightweight mesh (LW group) or with a non-absorbable heavyweight mesh (HW group).

Methods

Patients were assessed for pain at 1, 3 and 12 months by questionnaire, and were examined clinically at 12 months.

Results

Some 321 patients were included in an intention-to-treat analysis, 162 in the LW group and 159 in the HW group. At 12 months, significantly fewer patients in the LW group than in the HW group had pain of any severity: 39·5 versus 51·6 per cent (difference—12·1 (95 per cent confidence interval—23·1 to—1·0) per cent; P = 0·033). The recurrence rate was higher in the LW group (5·6 versus 0·4 per cent; P = 0·037). Five of eight recurrences in LW group were associated with a single participating centre.

Conclusion

Use of lightweight mesh was associated with less chronic pain but an increase in hernia recurrence after inguinal hernia repair. The latter may be related to technical factors associated with fixation of such meshes rather than any inherent defect in the mesh.

Surgical site infection after groin hernia repair

Background

Post-discharge surveillance for 30 days is needed to determine the true incidence of surgical site infection (SSI). This study was undertaken to determine the incidence of, and risk factors for, SSI after hernia repair.

Methods

A total of 3150 patients who had undergone groin hernia repair in 32 Scottish hospitals were telephoned 10, 20 and 30 days after operation to screen for SSI. Patients who believed the wound to be infected were seen by a healthcare worker to confirm the diagnosis. Details of operations and risk factors were obtained by case-note review.

Results

One hundred and four patients (3·3 per cent) declined to give a contact telephone number, leaving 3046 patients who agreed to take part in the study. Some 108 patients (3·4 per cent) could not be contacted at any point, giving a response rate of 93·3 per cent. Complete data were available for 2665 patients (87·5 per cent); 140 (5·3 per cent) developed SSI and 57 (2·1 per cent) thought the wound infected but this was not confirmed by the healthcare worker. Patients given a prophylactic antibiotic had a lower incidence of SSI (P = 0·002), but neither increase in the American Society of Anesthesiologists grade of fitness for operation nor prolonged duration of operation was a significant risk factor for infection.

Conclusion

SSI after hernia repair is common and large clinical trials are required to determine whether the use of prophylactic antibiotics reduces the incidence of infection.