Post-discharge surgical wound infection surveillance in a provincial hospital: follow-up rates, validity of data and review of the literature

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Surveillance for surgical site infections in orthopedic trauma surgeries at an Indian hospital

PURPOSE

Surgical site infections (SSIs) are one of the most common, causing substantial morbidity, mortality and are highly cost-effective means of reducing healthcare associated infections rates in health care set-ups. In India, there is no existing system for systematic surveillance of SSIs, encompassing post-discharge period.

METHODS

An indigenous SSI e-surveillance software was developed. Patients developing SSI as per standard definitions were included in the study. A denominator form and a case report form were filled for each case of SSI detected. The microbiological diagnosis was done as per standard methods. Logistic regression analysis was used to test for association of SSI and risk factors and determining the prevalence odds ratios.

RESULTS

Of the total of 850 patients enrolled in the SSI surveillance, 47 (5.5%) developed SSI. Most patients (490/850, 58%) underwent the open reduction internal fixation (ORIF) and also developed an SSI (33/490, 6.7%). Clean contaminated wound class and Dressing were found to be associated with increased risk of SSI significantly, Also increase in the length of stay was found to be associated with increased risk of SSI significantly. High antimicrobial resistance was observed in the microbial isolates recovered from SSIs. Patients who developed SSI had longer hospital stays.

CONCLUSIONS

Our study has been the first systematic surveillance effort in India, where patients were followed up till six months post surgeries. This pilot study was later expanded to other Indian hospitals. This network of SSI-Surveillance will lay the foundation for initiation of SSI-surveillance across the country.

A Novel Biofilm-Disrupting Wound Care Technology for the Prevention of Surgical Site Infections Following Total Joint Arthroplasty: A Conceptual Review

Surgical site infections (SSIs) are a major driver for increased costs following lower extremity joint arthroplasty procedures. It has been estimated that these account for over $2 billion in annual costs in the United States. While many of the current strategies for the prevention and treatment of SSIs target planktonic bacteria, 80 to 90% of bacterial pathogens exist in a sessile state. These sessile bacteria can produce extracellular polymeric substance (EPS) as protective barriers from host immune defenses and antimicrobial agents and thus, can be exceedingly difficult to eradicate. A novel wound care gel that disrupts the EPS and destroys the inciting pathogens has been developed for the treatment and prevention of biofilm-related infections. This is achieved by the simultaneous action of four key ingredients: (1) citric acid; (2) sodium citrate; (3) benzalkonium chloride; and (4) polyethylene glycol. Together, these constituents create a high osmolarity, pH-controlled environment that deconstructs and prevents biofilm formation, while destroying pathogens and promoting a moist environment for optimal wound healing. The available clinical evidence demonstrating the efficacy of this technology has been summarized, as well as the economic implications of its implementation and the authors' preferred method of its use. Due to the multifaceted burden associated with biofilm-producing bacteria in arthroplasty patients, this technology may prove to be beneficial for patients who have higher risks for infection, or perhaps, as a prophylactic measure to prevent infections for all patients.

Cost-effectiveness analysis of three methods of surgical-site infection surveillance: Less is more

BACKGROUND

A considerable proportion of surgical site infections (SSI) could be prevented by surveillance. The study aimed to compare the cost-effectiveness of 3 methods of SSI surveillance: Inpatient, phone, and out-patient clinic (OPC); to ensure that the risk of SSI is independent from loss-to-follow-up in phone and OPC surveillances, and to determine the reliability of phone surveillance.

METHODS

A cohort of 351 surgical patients were followed by 3 different surveillance methods: inpatient, follow-up in OPC and over the phone. Costs of nurse time and phone calls were expressed in 2019 USD. Effectiveness of surveillance was assessed using number of detected SSIs.

RESULTS

Phone surveillance was more cost-effective than OPC surveillance. Compared to inpatient surveillance, the OPC method costs USD 15.6 per extra detected SSI, whereas the phone method costs only USD 4.6 In phone and OPC surveillances, the risk of SSI was independent of loss-to-follow-up. However, the higher rate of SSI among OPC attendees raises the suspicion that the incidence of SSI estimated by OPC surveillance could be biased upward. Phone surveillance was reliable with high sensitivity and specificity.

CONCLUSIONS

Phone surveillance was a reliable cost-effective method. Inpatient surveillance was less effective, but it still can be used to detect severe SSI at low cost. While out-patient-clinic surveillance had the highest cost, the incidence estimated by it might be biased upward.

Multicentre randomised double-blind placebo controlled trial of combination vancomycin and cefazolin surgical antibiotic prophylaxis: the Australian surgical antibiotic prophylaxis (ASAP) trial

INTRODUCTION

Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established.

METHODS AND ANALYSIS

This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by The Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/102) on 9 July 2018. Study findings will be disseminated in the printed media, and learnt forums.

TRIAL REGISTRATION NUMBER

ACTRN12618000642280.

Impact of Postdischarge Surveillance on Surgical Site Infection Rates for Several Surgical Procedures Results From the Nosocomial Surveillance Network in The Netherlands

Objective.

To compare the number of surgical site infections (SSIs) registered after hospital discharge with respect to various surgical procedures and to identify the procedures for which postdischarge surveillance (PDS) is most important.

Design.

Prospective SSI surveillance with voluntary PDS. Recommended methods for PDS in the Dutch national nosocomial surveillance network are addition of a special registration card to the outpatient medical record, on which the surgeon notes clinical symptoms and whether a patient developed an SSI according to the definitions; an alternative method is examination of the outpatient medical record.

Setting.

Hospitals participating in the Dutch national nosocomial surveillance network between 1996 and 2004.

Results.

We collected data on 131,798 surgical procedures performed in 64 of the 98 Dutch hospitals. PDS was performed according to one of the recommended methods for 31,134 operations (24%) and according to another active method for 32,589 operations (25%), and passive PDS was performed for 68,075 operations (52%). Relatively more SSIs were recorded after discharge for cases in which PDS was performed according to a recommended method (43%), compared with cases in which another active PDS method was used (30%) and cases in which passive PDS was used (25%). The highest rate of SSI after discharge was found for appendectomy (79% of operations), followed by knee prosthesis surgery (64%), mastectomy (61%), femoropopliteal or femorotibial bypass (53%), and abdominal hysterectomy (53%).

Conclusions.

For certain surgical procedures, most SSIs develop after discharge. SSI rates will be underestimated if no PDS is performed. We believe we have found a feasible and sensitive method for PDS that, if patients routinely return to the hospital for a postdischarge follow-up visit, might be suitable for use internationally.

Impact of Postdischarge Surveillance on Surgical Site Infection Rates for Several Surgical Procedures Results From the Nosocomial Surveillance Network in The Netherlands

Objective.

To compare the number of surgical site infections (SSIs) registered after hospital discharge with respect to various surgical procedures and to identify the procedures for which postdischarge surveillance (PDS) is most important.

Design.

Prospective SSI surveillance with voluntary PDS. Recommended methods for PDS in the Dutch national nosocomial surveillance network are addition of a special registration card to the outpatient medical record, on which the surgeon notes clinical symptoms and whether a patient developed an SSI according to the definitions; an alternative method is examination of the outpatient medical record.

Setting.

Hospitals participating in the Dutch national nosocomial surveillance network between 1996 and 2004.

Results.

We collected data on 131,798 surgical procedures performed in 64 of the 98 Dutch hospitals. PDS was performed according to one of the recommended methods for 31,134 operations (24%) and according to another active method for 32,589 operations (25%), and passive PDS was performed for 68,075 operations (52%). Relatively more SSIs were recorded after discharge for cases in which PDS was performed according to a recommended method (43%), compared with cases in which another active PDS method was used (30%) and cases in which passive PDS was used (25%). The highest rate of SSI after discharge was found for appendectomy (79% of operations), followed by knee prosthesis surgery (64%), mastectomy (61%), femoropopliteal or femorotibial bypass (53%), and abdominal hysterectomy (53%).

Conclusions.

For certain surgical procedures, most SSIs develop after discharge. SSI rates will be underestimated if no PDS is performed. We believe we have found a feasible and sensitive method for PDS that, if patients routinely return to the hospital for a postdischarge follow-up visit, might be suitable for use internationally.

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Procedure-specific surgical site infection incidence varies widely within certain National Healthcare Safety Network surgery groups

BACKGROUND

The National Healthcare Safety Network (NHSN) classifies surgical procedures into 40 categories. The objective of this study was to determine surgical site infection (SSI) incidence for clinically defined subgroups within 5 heterogeneous NHSN surgery categories.

METHODS

This is a retrospective cohort study using the longitudinal State Inpatient Database. We identified 5 groups of surgical procedures (amputation; bile duct, liver or pancreas [BILI]; breast; colon; and hernia) using ICD-9-CM procedure codes in community hospitals in California, Florida, and New York from January 2009-September 2011 in persons aged ≥18 years. Each of these 5 categories was classified to more specific surgical procedures within the group. The 90-day SSI rates were calculated using ICD-9-CM diagnosis codes.

RESULTS

There were 62,901 amputation surgeries, 33,358 BILI surgeries, 72,058 breast surgeries, 125,689 colon surgeries, and 85,745 hernia surgeries in 349,298 people. The 90-day SSI rates varied significantly within each of the 5 subgroups. Within the BILI category, bile duct, pancreas, and laparoscopic liver procedures had SSI rates of 7.2%, 17.2%, and 2.2%, respectively (P < .0001 for each) compared with open liver procedures (11.1% SSI).

CONCLUSION

The 90-day SSI rates varied widely within certain NHSN categories. Risk adjustment for specific surgery type is needed to make valid comparisons between hospitals.

Multi-Center Randomized Controlled Trial on the Effect of Triclosan-Coated Sutures on Surgical Site Infection after Colorectal Surgery

BACKGROUND

Surgical site infection (SSI) remains the most frequent complication after colorectal resection. The role of sutures coated with antimicrobial agents such as triclosan in reducing SSI is controversial.

METHODS

This was a multi-center randomized controlled trial with patients and outcome assessors blinded to treatment. The study was performed in four university referral hospitals. Patient candidates for elective colorectal resection were assigned randomly to abdominal incision closure with polyglactin 910 triclosan-coated sutures (triclosan group) or with polyglactin 910 without triclosan (control group). The primary outcome was the rate of SSI within 30 d after hospital discharge. The secondary outcomes were the overall rate of incision complications and length of hospital stay (LOS).

RESULTS

Two hundred eighty-one patients (triclosan group: 140; control group: 141) were analyzed after randomization. The rate of SSI was 12.9% (18/140) in the triclosan group versus 10.6% (15/141) in the control group (odds ratio: 1.24; 95% confidence interval: 0.60-2.57; p=0.564). Secondary outcome analysis showed an overall incision complication rate of 38.3% in the control group versus 45.7% in the triclosan group (odds ratio: 1.36; 95% confidence interval: 0.84-2.18; p=0.208). Median LOS was 11 d in both groups (p=0.55).

CONCLUSIONS

Surgical sutures coated with triclosan do not appear to be effective in reducing the rate of SSI.

Strategies to prevent surgical site infections in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,”1 published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.2

Assessing surgical site infection risk factors using electronic medical records and text mining

Text mining techniques to detect surgical site infections (SSI) in unstructured clinical notes were used to improve SSI detection. In conjuction with data from an integrated electronic medical record, all of the 22 SSIs detected by traditional hospital-based surveillance were found using text mining, along with an additional 37 SSIs not detected by traditional surveillance.

[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.

A novel method of surgical site infection surveillance after cardiac surgery by active participation of stake holders

We describe a comprehensive surveillance system involving infection control practitioners, surgeons, administrative staff, and patients aimed at improving the postdischarge surveillance of surgical site infections. The system was able to detect 22 infections out of 538 procedures, 95% of which were detected during the postdischarge period.

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.

[Incidence of nosocomial infection in open prostate surgery]

OBJECTIVES

To know the rate of nosocomial infections in open prostate surgery and to assess the application of pre-surgery preparation and preoperative antibiotic prophylaxis protocols at three public hospitals in the Autonomous Community of Madrid.

MATERIALS AND METHODS

Prospective observational and multicentre study, including all the patients operated on at the services monitored and admitted for more than 48 hours between 1 January and 31 December 2009. They were monitored from admittance until their discharge.

RESULTS

The rate of hospital infection observed was 3.38%. The most frequent infection was surgical localization, with an incidence rate of 2.77% (superficial=1.23%; deep=0.31%; organ-space=1.23%). The percentage of appropriate surgical prophylaxis, both in the indication and in the selection of antibiotics, initiation and duration, with respect to all those patients that received it, was 47.42%. According to the data obtained from their clinical records, the percentage of patients in which the pre-surgery preparation protocol was correctly complied with, was 92%.

CONCLUSIONS

The results obtained in this multicentre study can serve not only as a reference to other public hospitals, but they are also comparable to other international monitoring systems. Monitoring and controlling infections associated with healthcare must be a key aspect in Patient Care and Safety programmes.

[Etiology of surgical site infections at the orthopaedic trauma units]

OBJECTIVES

The aim of the study was to analyze the epidemiological and microbiological analysis of surgical site infections in the orthopedic wards.

MATERIALS AND METHODS

A 6-month prospective cohort study was conducted at the major teaching hospital in Belgrade. Patient's basic demographic data and data about surgical site infections were collected. Bacteria cultured from the surgical site were also analyzed.

RESULTS

A total of 277 patients operated in the Institute of Orthopedics and trauma surgery, Clinical Center of Serbia. Sixty-three cases of SSI were detected, and the overall incidence rate was 22.7% (95% IP = 17.8-27.6). Fifty-three (84.1%) SSIs had microbiological confirmation and overall 82 bacterial strains were isolated. The most frequent isolated bacteria were Staphylococcus aureus, Acinetobacter sp, Klebsiella pp, Pseudomonas sp and Enterococcus sp. Nineteen (79.2%) strains of Staphylococcus aureus isolated from infected surgical sites were meticillin- resistant.

CONCLUSION

This study suggests that it is necessary to maintain continuous surveillance of surgical site infections. It is important to emphasize the need for implementation the measures of contact isolation in order to prevent the nosocomial transmission of resistant bacteria.

Vigilância pós-alta das infecções de sítio cirúrgico em crianças e adolescentes em um hospital universitário de Belo Horizonte, Minas Gerais, Brasil

As infecções hospitalares são as principais complicações na prática cirúrgica e, dentre estas, as infecções de sítio cirúrgico são as mais freqüentes. Apesar dessas infecções poderem se manifestar após a alta, no Brasil, a maioria dos serviços não faz vigilância pós-alta. Para avaliar a importância dessa vigilância e o perfil das infecções em crianças e adolescentes, acompanhou-se uma coorte de 730 pacientes cirúrgicos de um hospital universitário de Belo Horizonte, Minas Gerais, Brasil, de 1999 a 2001. Calculou-se a incidência acumulada, aplicou-se o teste t de Student na comparação de médias e o método de Kaplan-Meier na análise do tempo de ocorrência das infecções; considerou-se significativo o valor p < 0,05. Foram diagnosticadas 87 infecções de sítio cirúrgico na coorte estudada, sendo 37% após a alta hospitalar. A taxa de incidência de infecções de sítio cirúrgico foi de 11,9%; mas seria apenas de 7,5% sem o controle pós-alta. Verificou-se no grupo dos pacientes com infecções identificadas após a alta uma média de aparecimento das infecções de 11,3 ± 6,4 dias; que os tempos de permanência pré e pós-operatórios foram significativamente menores em relação aos pacientes com infecções intra-hospitalares. O estudo indica que a vigilância pós-alta é importante para se conhecer a real incidência das infecções de sítio cirúrgico.

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.

Costs of surgical site infections that appear after hospital discharge

Data were collected from surgical patients in the hospital and on 4 occasions postdischarge. The incidence of postdischarge surgical site infection was 8.46%. Strong evidence showed that these infections caused minor additional costs, which contradicts existing literature. We discuss why previous studies might have overstated costs.

Caesarean section surgical site infection surveillance

Surveillance of surgical site infection (SSI) is an important infection control activity. The Caesarean section procedure was selected, as part of the Scottish Surveillance of Healthcare Associated Infection Programme, to monitor and report upon the incidence of SSI. Data were collected prospectively for 715 patients undergoing a Caesarean section procedure for 35 weeks during the latter months of 2002 and the first quarter of 2003. Of these, 80 (11.2%) patients developed an SSI, 57 (71%) of which were detected by postdischarge surveillance. Risk factors associated with infection were analysed. The choice of subcuticular suture rather than staples to close the surgical site was associated with a significantly lower incidence of infection (P=0.021). Obese women experienced significantly more infections than women with a normal body mass index (P=0.028). Dissemination of the surveillance results has made clinicians aware of the influence of body mass index and choice of skin closure in relation to SSI in this patient population. Analysis of these data has led to a review of local practice. The results also indicate the importance of postdischarge surveillance if SSIs are to be detected in this patient group. Continuous data collection and timely dissemination of the results are important factors acting as the catalyst for a review of practice.

Improved detection of orthopaedic surgical site infections occurring in outpatients

To test the hypothesis that a simple method of text searching of standard dictated outpatient clinic notes could be used to detect postoperative infections that otherwise were undetected by the traditional hospital-based infection surveillance methods, a retrospective analysis of all clinical notes from the orthopaedic surgery service of a tertiary care medical center without an electronic medical record system was done. Text-searching algorithms were used to screen all outpatient clinic notes for patients seen between September, 2000 and May, 2001. Clinic notes were screened using specific search terms indicative of surgical site infection, to yield a subset of notes that then were manually reviewed. The identified 18,887 notes were reduced to 558 screen-positive notes, of which 347 notes (197 patients) had confirmed surgical site infections on manual review (positive predictive value, 62.2%). Eighty percent of the total joint infections and 54% of the spine infections were not detected through standard hospital-based surveillance. This simple, inexpensive, method for screening clinic notes is effective in improving detection of postdischarge surgical site infections (and, therefore, quality assessment for surgery). It can be implemented in most current clinical settings.

LEVEL OF EVIDENCE

Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients--with universally applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

Assessing patient safety in the United States: challenges and opportunities

BACKGROUND

In 1999, the US Congress mandated the Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services (DHHS), to report annually to the nation about healthcare quality. One chapter in the National Healthcare Quality Report (NHQR) is focused on patient safety.

OBJECTIVES

The objectives of this study were to describe the challenges in reporting the national status on patient safety for the first NHQR and discuss emerging opportunities to improve the comprehensiveness and reliability of future reporting.

RESEARCH DESIGN

This study is a selective review of definitions, frameworks, data sources, measures, and emerging developments for assessing patient safety in the United States.

RESULTS

Available data and measures for patient safety assessment in the nation are inadequate, especially for comparing regions and subpopulations and for trend analysis. However, many opportunities are emerging from the recently increased investments in patient safety research and many ongoing safety improvement efforts in the private sector and at the federal, state, and local government levels.

CONCLUSION

There are many challenges in assessing national performance on patient safety today. Ongoing developments on multiple fronts will provide data and measures for more accurate and more comprehensive assessments of patient safety for future NHQRs.

The Hospital Infection Standardised Surveillance (HISS) programme: analysis of a two-year pilot

In 1998 the New South Wales (NSW) Health Department funded the development and implementation of the State's first standardized methodology for the surveillance of healthcare-associated infection for public hospitals. Fifteen pilot hospitals targeted inpatient groups considered to represent their core patient groups to act as sentinel measurements of patient safety. The aggregated rates of surgical site infection for coronary artery bypass graft (CABG) (chest & leg) surgery was 1.7% (95%CI: 1.1-2.5), CABG (chest only) 2.1% (95%CI: 1.0-3.7), vascular 7.1% (95%CI: 4.6-10.3), hip prosthesis 1.3% (95%CI: 0.5-2.7), knee prosthesis 6.1% (95%CI: 2.8-11.2) and colorectal 12.5% (95%CI: 9.5-16.1). The development of a bloodstream infection (BSI) associated with a central venous catheter (CVC) was not significantly (P=0.6) different when examined by duration of exposure with 3.7 BSI per 1000 line-days for CVC in situ six or more days compared with 4.0 BSI per 1000 line-days for CVC in situ for five or less days. A significantly (P<0.0001) greater proportion of patients whose CVC was in situ six or more days (6.8 per 100 patients, 95%CI: 4.2-10.2) developed a BSI compared with the proportion of patients whose CVC was in situ for five or fewer days (0.6 per 100 patients, 95%CI: 0.3-1.3). Significantly (P<0.0001) different rates of patients acquiring a new methicillin-resistant Staphylococcus aureus infection were found when hospital type was examined with rates ranging from 0.2 to 5.0 per 10000 occupied acute-care bed-days. The pilot highlighted that the collection of data for aggregation of some procedures and intravascular catheters may take many years before a reliable benchmark can be identified and many hospitals may not achieve reliable local rates annually. For surveillance to provide timely measures of patient safety we should consider surveillance methods for many small to medium sized hospitals that includes active surveillance only for infections with concurrent passive surveillance of the relevant denominators.

Occlusive wrap dressing reduces infection rate in saphenous vein harvest site

BACKGROUND

Infection in the saphenous vein harvest site is a common problem. We developed an occlusive circumferential wrap dressing technique that reduces skin edge tension, eliminates dead space, and prevents external contamination. We compared the surgical site infection rate using the wrap dressing technique with that of standard longitudinal dressings. METHODS. One hundred fifty-two consecutive patients were randomly assigned to receive either standard dressings or the wrap dressing. Data were collected in the hospital and then 4 to 6 weeks postoperatively. Superficial and deep wound infections were defined by the standard criteria from the Centers for Disease Control and Prevention.

RESULTS

The infection rate in the wrap group was 14% compared with 35%, for the standard group (p = 0.006). Multivariate analysis showed that wrap technique was the only significant predictor (negative) of infection (odds ratio, 0.19; p = 0.001).

CONCLUSIONS

In saphenous vein harvest wounds, the occlusive wrap dressing technique has the potential to reduce the rate of infection by 50%. This simple and inexpensive technique is also readily applicable to the radial artery harvest site in the arm and may provide similar benefit.