The Surgical Infection Prevention Project: Processes, Outcomes, and Future Impact

The Cost of Surgical Site Infections after Colorectal Surgery in the United States from 2001 to 2012: A Longitudinal Analysis

Surgical site infections (SSIs) are among the most common types of postoperative complications in the United States and are associated with significant prevalence of morbidity and mortality in patients undergoing surgical interventions, especially in colorectal surgery (CRS) where SSI rates are significantly higher than those of similar operative sites. SSIs were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2012 based on the specification of an ICD-9 code. Propensity score matching was used to compare costs associated with SSI cases with those of non-SSI controls among elective and nonelective admissions. Results were projected nationally using Healthcare Cost and Utilization Project sampling methodology to evaluate the incidence of SSIs and ascertain the national cost burden retrospectively. Among 4,851,359 sample-weighted hospitalizations, 4.2 per cent (203,597) experienced SSI. Elective admissions associated with SSI-stayed hospitalized for an average of 7.8 days longer and cost $18,410 more than their counterparts who did not experience an SSI. Nonelective admissions that experienced an SSI had an 8.5-day longer hospital stay and cost $20,890 more than counterparts without perioperative infections. This represents a 3 per cent annual growth in costs for SSIs and seems to be largely driven by cost increases in treatment of SSIs for elective surgeries. Current efforts of SSI management after CRS focused on compliance with guidelines and tracking of infection rates would benefit from some improvements. Considering the growing costs and increase in resource utilization associated with SSIs from 2001 to 2012, further research on costs associated with management of SSIs specific to CRS is necessary.

Risk factors for superficial surgical site infection after elective rectal cancer resection: a multivariate analysis of 8880 patients from the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Superficial surgical site infection (sSSI) is one of the most common complications after colorectal resection. The goal of this study was to determine the comorbidities and operative characteristics that place patients at risk for sSSI in patients who underwent rectal cancer resection.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried (via diagnosis and Current Procedural Terminology codes) for patients with rectal cancer who underwent elective resection between 2005 and 2012. Patients for whom data concerning 27 demographic factors, comorbidities, and operative characteristics were available were eligible. A univariate and multivariate analysis was performed to identify possible risk factors for sSSI.

RESULTS

A total of 8880 patients met the entry criteria and were included. sSSIs were diagnosed in 861 (9.7%) patients. Univariate analysis found 14 patients statistically significant risk factors for sSSI. Multivariate analysis revealed the following risk factors: male gender, body mass index (BMI) >30, current smoking, history of chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists III/IV, abdominoperineal resection (APR), stoma formation, open surgery (versus laparoscopic), and operative time >217 min. The greatest difference in sSSI rates was noted in patients with COPD (18.9 versus 9.5%). Of note, 54.2% of sSSIs was noted after hospital discharge. With regard to the timing of presentation, univariate analysis revealed a statistically significant delay in sSSI presentation in patients with the following factors and/or characteristics: BMI <30, previous radiation therapy (RT), APR, minimally invasive surgery, and stoma formation. Multivariate analysis suggested that only laparoscopic surgery (versus open) and preoperative RT were risk factors for delay.

CONCLUSIONS

Rectal cancer resections are associated with a high incidence of sSSIs, over half of which are noted after discharge. Nine patient and operative characteristics, including smoking, BMI, COPD, APR, and open surgery were found to be significant risk factors for SSI on multivariate analysis. Furthermore, sSSI presentation in patients who had laparoscopic surgery and those who had preoperative RT is significantly delayed for unclear reasons.

Surgical site infection: poor compliance with guidelines and care bundles

Surgical site infections (SSIs) are probably the most preventable of the health care-associated infections. Despite the widespread international introduction of level I evidence-based guidelines for the prevention of SSIs, such as that of the National Institute for Clinical Excellence (NICE) in the UK and the surgical care improvement project (SCIP) of the USA, SSI rates have not measurably fallen. The care bundle approach is an accepted method of packaging best, evidence-based measures into routine care for all patients and, common to many guidelines for the prevention of SSI, includes methods for preoperative removal of hair (where appropriate), rational antibiotic prophylaxis, avoidance of perioperative hypothermia, management of perioperative blood glucose and effective skin preparation. Reasons for poor compliance with care bundles are not clear and have not matched the wide uptake and perceived benefit of the WHO 'Safe Surgery Saves Lives' checklist. Recommendations include the need for further research and continuous updating of guidelines; comprehensive surveillance, using validated definitions that facilitate benchmarking of anonymised surgeon-specific SSI rates; assurance that incorporation of checklists and care bundles has taken place; the development of effective communication strategies for all health care providers and those who commission services and comprehensive information for patients.

Infections in vascular surgery

Infections in vascular surgery are usually of multifactorial nature resulting from a complex interplay of patient, surgical and environmental factors. Preventative measures initiated from the stage of pre-operative screening, maintenance of patient homeostasis and the use of organism-directed antibiotics can contribute to reduce infection rates. Graft preservation techniques are becoming increasingly popular as a method to treat established graft infections. In this article we report on the current trends and techniques on the management of infections in vascular surgery. Ongoing studies are required to continue to accumulate data on the effectiveness of these techniques.

Point-of-care electronic prompts: an effective means of increasing compliance, demonstrating quality, and improving outcome

BACKGROUND

Incentives based on quality indicators such as the Surgical Care Improvement Project core measures (SCIP 1) encourage implementation of evidence-based guidelines consistently into clinical practice. Information systems with point-of-care electronic prompts (POCEPs) can facilitate adoption of processes and benchmark performance. We evaluated the effectiveness of POCEPs on rates of antibiotic administration within 60 minutes of surgical incision and effect on outcome in a prospective observational trial.

METHODS

SCIP 1 compliance and the corresponding outcome variable (surgical site infection [SSI]) were examined prospectively over 2 consecutive 6-month periods before (A) and after (B) POCEPs implementation at a regional health system. Secondary analysis extended the observation to two 12-month periods (A' and B'). A 2-year (C and D) sustainability phase followed.

RESULTS

The 19,744 procedures included 9127 and 10,617 procedures before (A) and after (B) POCEPs implementation, respectively. POCEPs increased compliance with SCIP indicators in period B by 31% (95% CI, 30.0%-32.2%) from 62% to 92% (P < 0.001) and were associated with a sustainable, contemporaneous decrease in the incidence of SSI from 1.1% to 0.7% (P = 0.003; absolute risk reduction, 0.4%; 95% CI, 0.1%-0.7%). Secondary and sustainability analysis revealed that compliance rates remained >95% with mean SSI rates lower for all periods compared with pre-POCEPs SSI rates (0.8%, 0.7%, and 0.5% vs 1.1%; P < 0.001).

CONCLUSIONS

POCEPs increased compliance with SCIP indicators by >30% and were associated with a 0.4% absolute risk reduction in the incidence of SSI. POCEPs may be useful to modulate provider behavior and demonstrate intraoperative quality and value.

The impact of ineffective and inefficient care on the excess costs of elective surgical procedures

BACKGROUND

Ineffective and inefficient elective surgical care has been identified as a major factor accounting for excessive costs of elective surgical procedures. The identification of cost-effective hospitals permits objective measurement of excessive surgical costs and development of strategies to improve outcomes and efficiency.

STUDY DESIGN

We used the 2002 to 2005 National Inpatient Sample from the Healthcare Cost and Utilization Project for colorectal resections, elective coronary bypass grafts, total hip replacement, and hysterectomy to assess hospitals' risk-adjusted adverse outcome rates and costs. Adverse outcomes were defined as inpatient deaths or prolonged risk-adjusted postoperative lengths of stay (RApoLOS). Risk-adjusted costs were determined for all patients, using hospital-specific cost-to-charge ratios to convert charges to costs. Effective, efficient hospitals were identified to serve as a reference standard. Outlier hospitals for ineffectiveness (p < 0.005) and inefficiency (p < 0.0005) were analyzed to measure excessive costs relative to reference hospitals.

RESULTS

Hospital costs for the 4 operations combined were $325 million greater (8%) than predicted based on the reference standard. A total of 95% of excessive costs were due to inefficiency and only 5% were due to higher-than-predicted adverse outcomes rates. Elimination of predicted excess costs of all adverse outcomes for all 4 procedures at all hospitals studied would result in smaller savings than elimination of inefficiency-associated costs at inefficient hospitals alone.

CONCLUSIONS

Inefficiency is substantially more important than suboptimal outcomes in accounting for the excessive hospital costs of elective surgical care in this study population.

Surgical site infections: Causative pathogens and associated outcomes

BACKGROUND

Surgical site infections (SSIs) are associated with substantial morbidity, mortality, and cost. Few studies have examined the causative pathogens, mortality, and economic burden among patients rehospitalized for SSIs.

METHODS

From 2003 to 2007, 8302 patients were readmitted to 97 US hospitals with a culture-confirmed SSI. We analyzed the causative pathogens and their associations with in-hospital mortality, length of stay (LOS), and cost.

RESULTS

The proportion of methicillin-resistant Staphylococcus aureus (MRSA) significantly increased among culture-positive SSI patients during the study period (16.1% to 20.6%, respectively, P < .0001). MRSA (compared with other) infections had higher raw mortality rates (1.4% vs 0.8%, respectively, P=.03), longer LOS (median, 6 vs 5 days, respectively, P < .0001), and higher hospital costs ($7036 vs $6134, respectively, P < .0001). The MRSA infection risk-adjusted attributable LOS increase was 0.93 days (95% confidence interval [CI]: 0.65-1.21; P < .0001), and cost increase was $1157 (95% CI: $641-$1644; P < .0001). Other significant independent risk factors increasing cost and LOS included illness severity, transfer from another health care facility, previous admission (<30 days), and other polymicrobial infections (P < .05).

CONCLUSION

SSIs caused by MRSA increased significantly and were independently associated with economic burden. Admission illness severity, transfer from another health care setting, and recent hospitalization were associated with higher mortality, increased LOS, and cost.

[Association between the pattern of prophylactic antibiotic use and surgical site infection rate for major surgeries in Korea]

OBJECTIVES

The purpose of this study was to analyze the association between the pattern of prophylactic antibiotic use (PAU) and the surgical site infection (SSI) rate for major surgeries in Korea.

METHODS

We retrospectively reviewed the medical records of patients who underwent cardiac, colon and gastric surgery, hysterectomies and hip/knee replacements at 20 hospitals, and inclusive of over 500 beds. We randomly sampled 60 cases per surgery type for patients discharged between September and November, 2006. A total fo 2,924 cases were included in our analysis. Cox's proportional hazard analysis was conducted to evaluate the association between the pattern of PAU and SSI rate.

RESULTS

The proportion of patients who received their first prophylactic antibiotics (PA) 1 hour before incision was 65.5%, who received inappropriate PAs was 80.8%, and the proportion of patients whose PA was discontinued within 24 hours of surgery was 0.5%. The average duration of PAU after surgery was 9 days. The relative risk (RR) of SSI in patients who received their first PA more than 1 hour before incision was significantly higher than for those who received it within 1 hour prior to incision (RR=8.20, 95% CI=4.81-13.99). Inappropriate PA selection increased SSI rate, albeit with marginal significance (RR=1.97, 95% CI=0.96-4.03). Also, prolonged PAU following surgery had no effect on SSI rate.

CONCLUSIONS

These results suggest that the pattern of PAU in the surgeries examined was not appropriate. Errors in the timing of PAU and of PA selection increase SSI rate. SSI rate remained unaltered following prolonged PAU after surgery.

Implementation of quality measures to reduce surgical site infection in colorectal patients

PURPOSE

The goal of this study was to determine the rate of surgical site infection and compliance with process measures designed to prevent infection in a defined population of patients undergoing colorectal operations.

METHODS

A task-force consisting of surgeons, hospital infection control personnel, anesthesiologists, and nurses was convened to enforce the use of process measures to prevent infections. We monitored antibiotic selection, dosage, timing, redosing and discontinuation, hair removal technique, intraoperative and postoperative body temperature, and perioperative glucose control for 12 months by using electronic medical records. Patients underwent a minimum of 30 days of postoperative follow-up and the attending surgeon diagnosed infections.

RESULTS

Between April 2006 and March 2007, 298 patients underwent abdominal colorectal operations. The overall infection rate was 20 percent for colon procedures and 11 percent for small-bowel procedures. Compliance for most process measures improved from the first to the fourth quarter, and during the final quarter, correct antibiotic dose and hair removal with clippers exceeded 90 percent.

CONCLUSIONS

The rate of surgical site infection after colorectal surgery is likely to be higher than that reported in national quality improvement programs. Perfect compliance with performance measures may be difficult to attain.

Risk factors associated with surgical site infection and the development of short-term complications in macaques undergoing indwelling vascular access port placement

BACKGROUND

Risk factors associated with surgical site infection (SSI) and the development of short-term complications in macaques undergoing vascular access port (VAP) placement are evaluated in this study.

METHODS

Records from 80 macaques with VAPs were retrospectively reviewed. Logistic regression was used to identify factors associated with short-term post-operative complications.

RESULTS

The primary outcome was SSI, which occurred in 21.6% (52.6% in the first 12 months vs. 13% thereafter) of procedures. SSI was associated with major secondary complications including VAP removal (11.4%), wound dehiscence (5.7%), and mechanical catheter occlusion (5.7%). In multivariate modeling, only surgical program progress was a statistically significant predictor of SSI, while animal compliance had a slightly protective effect.

CONCLUSIONS

Vascular access ports have a moderate risk of complications, provided the surgical program optimizes best practices. Under complex experimental conditions, VAPs represent an important refinement, both improving animals' overall well-being and environment and reducing stress.

Variation in the rates of do not resuscitate orders after major trauma and the impact of intensive care unit environment

BACKGROUND

There is an increased emphasis on benchmarking of trauma mortality outcomes as a measure of quality. Differences in approaches to end-of-life care or perceptions of salvageability might account for some of the variability in outcomes across centers. We postulated that these differences in perceptions or practice might lead to significant variation in the use of do not resuscitate (DNR) orders and sought to identify institutional characteristics associated with their use.

METHODS

Patients surviving >24 hours and admitted to an intensive care unit (ICU) in one of 68 centers across the United States were identified from a large prospective cohort study of severely injured patients. Independent predictors of a DNR order at both the patient and institutional level were identified using multivariate hierarchical modeling stratified by age <55 or >/=55.

RESULTS

Of 6,765 patients, 7% had a DNR order, of whom 88% died. The proportion of patients in each center with a DNR order ranged from 0% to 57%. Independent patient-level predictors associated with a DNR order were increasing age, preinjury comorbidity burden, severe injury, and organ failure. Institutional predictors of DNR orders differed by age. Care in an open ICU was associated with a DNR order (odds ratio, 1.7; 95% confidence interval, 1.0-3.0) in the elderly, whereas care in a combined medical-surgical ICU (vs. surgical or trauma ICU) was associated with greater likelihood (odds ratio, 2.0; 95% confidence interval, 1.1-4.1) of a DNR order in the young.

CONCLUSIONS

DNR orders are relatively common in seriously injured trauma patients, and there is significant variability in their use across centers. Given the institutional characteristics independently associated with DNR status, it is likely that both differences in the ethos of end-of-life care and perceptions of salvageability affect decision making.

Surgical site infection: the host factor

More than 30 million surgical procedures are performed annually in the United States, and surgical site infections (SSIs) remain a major postoperative complication. Although bacteria contaminate all surgical wounds, not all wounds become infected. In most cases, the host response eradicates the microbes. The patient's (ie, host's) responsiveness, therefore, is an important variable in the equation of factors that influence the rate of infection. Optimizing the patient's physiological condition can help prevent SSIs. Initiatives that show promise in reducing SSI rates include use of supplemental oxygen, maintenance of core body temperature, and rigorous management of blood sugar. Perioperative nurses play an important role as the patient's infection control advocate.

The Effect of an Interactive Visual Reminder in an Anesthesia Information Management System on Timeliness of Prophylactic Antibiotic Administration

BACKGROUND

To reduce the incidence of surgical site infection, preoperative antibiotics should be administered within 60 min before surgical incision. The purpose of this study was to determine whether adding a visual interactive electronic reminder with a message related to antibiotic administration to our anesthesia information management system would increase compliance with prophylactic antibiotic guidelines.

METHODS

We retrospectively studied electronic anesthesia records of ambulatory and day-of-surgery admission surgical cases in which one of our usual prophylactic antibiotics was administered from June 2004 through December 2005, an interval that includes cases both before and after the February 2005 implementation of the new reminder. Compliance was defined as documented antibiotic administration within 60 min before the surgical procedure starting time. Noncompliant cases were divided into those in which dosing was too early or too late.

RESULTS

Compliance for 4987 cases before and 9478 cases after the reminder was implemented increased from 82.4% to 89.1% (P < 0.01). This increase was found both for attending anesthesiologists assisted by a resident or nurse anesthetist (82.9% before vs 89.1% after, P < 0.01) and for attending anesthesiologists working alone (80.1% before vs 89.3% after, P < 0.01). The improvement in compliance was associated with a decrease in the incidence of antibiotics administered too late (i.e., after surgical incision) (15.2% before vs 8.1% after, P < 0.01), but with no significant change in the incidence of antibiotics administered too early (i.e., more than 60 min before skin incision) (2.4% before vs 2.8% after, P = 0.07).

CONCLUSIONS

The implementation of a visual interactive electronic reminder regarding administration of preoperative antibiotics in an anesthesia information management system was associated with a sustained increase in compliance with surgical prophylactic antibiotic administration timing guidelines.

Inadequate antimicrobial prophylaxis during surgery: a study of beta-lactam levels during burn debridement

OBJECTIVES

To determine how long single-dose prophylactic antibiotic regimens for burns surgery maintained plasma concentrations above the MICs for target organisms during surgery.

PATIENTS AND METHODS

We monitored antibiotic plasma concentrations in 12 patients (mean +/- SD 43 +/- 12% total burn surface area) throughout debridement surgery after administration of the standard prophylactic antibiotic dosing regimens of either 1 g of intravenous cefalotin or 4.5 g of intravenous piperacillin/tazobactam.

RESULTS

The eschar debridement and grafting procedures ranged in duration from 2.25 to over 8.5 h. The duration of total plasma cefalotin concentration above an MIC of 0.2 mg/L for Staphylococcus aureus was 6.49 +/- 2.85 h, whereas the mean duration of total plasma piperacillin concentration above an MIC of 64 mg/L for Pseudomonas aeruginosa was only 1.15 +/- 0.59 h. None of the patients dosed with piperacillin/tazobactam was adequately protected for the duration of their surgery and adequate prophylaxis was only evident in four of the nine patients administered cefalotin.

CONCLUSIONS

These results suggest a need to review antibiotic prophylaxis dosage regimens for burns surgery and the adoption of regimens that will minimize the risk of infection in this high-risk patient group. It is suggested that the antibiotic prophylaxis guideline for burn debridement surgery be modified to include re-dosing or a continuous infusion of beta-lactam antibiotics.