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Stephens IJB, Murphy B, Burns L, McCawley N, McNamara DA, Burke JP. Contemporary perioperative outcomes after total abdominal colectomy for ulcerative colitis in a tertiary referral centre. Eur J Gastroenterol Hepatol 2024; 36:578-583. [PMID: 38489595 DOI: 10.1097/meg.0000000000002755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Colectomy for ulcerative colitis (UC) is common despite therapeutic advances. Post-operative morbidity and mortality demonstrate an association between hospital volumes and outcomes. This single-centre retrospective study examines outcomes after emergency colectomy for UC. METHODS Patient demographics, perioperative variables and outcomes were collected in Beaumont Hospital between 2010 and 2023. Univariant analysis was used to assess relationships between perioperative variables and morbidity and length of stay (LOS). RESULTS A total of 115 patients underwent total abdominal colectomy with end ileostomy for UC, 8.7 (±3.8) per annum. Indications were refractory acute severe colitis (88.7%), toxic megacolon (6.1%), perforation (4.3%), or obstruction (0.9%). Over 80% of cases were performed laparoscopically. Pre-operative steroid (93%) and biologic (77.4%) use was common. Median post-operative LOS was 8 days (interquartile range 6-12). There were no 30-day mortalities, and 30-day post-operative morbidity was 38.3%. There was no association between time to colectomy ( P = 0.85) or biologic use ( P = 0.24) and morbidity. Increasing age was associated with prolonged LOS ( P = 0.01). Laparoscopic approach (7 vs. 12 days P =0.01, 36.8% vs. 45% P = 0.66) was associated with reduced LOS and morbidity. CONCLUSION This study highlights contemporary outcomes after emergency colectomy for UC at a specialist high-volume, tertiary referral centre, and superior outcomes after laparoscopic surgery in the biologic era.
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Affiliation(s)
- Ian J B Stephens
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
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Boyce JM. Best products for skin antisepsis. Am J Infect Control 2023; 51:A58-A63. [PMID: 37890954 DOI: 10.1016/j.ajic.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections. METHODS A PubMed search was performed to update the evidence on skin antiseptic products and practices. RESULTS Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs. CONCLUSIONS Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.
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White C, Kurtz S, Lusk L, Wilson B, Britton V, Hayden K, Hunt S, Hyland J, Kittrell W, Maddox J, Tanner A, Tucker V. Implementation of a Colorectal Surgical Site Infection Prevention Bundle and Checklist: A Quality Improvement Project. AORN J 2023; 118:297-305. [PMID: 37882597 DOI: 10.1002/aorn.14020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/10/2022] [Accepted: 11/25/2022] [Indexed: 10/27/2023]
Abstract
After noting an elevated surgical site infection rate in 2019 associated with colorectal surgeries, leaders at two Central Virginia health system hospitals convened an interdisciplinary team to audit current practices and research infection prevention strategies. After identifying a lack of standardization in care processes for colorectal surgery patients and reviewing the literature on colorectal bundles, the team created a bundle focusing on the use of antibiotics, chlorhexidine gluconate wipes or baths, separate closing instrument trays, nasal decolonization, bowel preparation, and maintaining patient normothermia. After synthesis and stakeholder input, the team implemented the colorectal bundle along with a checklist for all users to complete to ensure compliance and standardization of practice and for auditing purposes. Implementation results were positive: the total number of colorectal infections decreased from nine in 2020 to three in 2021. Education was critical to securing staff member engagement for successful implementation of and compliance with the bundle.
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Silver CM, Yang AD, Shan Y, Love R, Prachand VN, Cradock KA, Johnson J, Halverson AL, Merkow RP, McGee MF, Bilimoria KY. Changes in Surgical Outcomes in a Statewide Quality Improvement Collaborative with Introduction of Simultaneous, Comprehensive Interventions. J Am Coll Surg 2023; 237:128-138. [PMID: 36919951 DOI: 10.1097/xcs.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes. STUDY DESIGN Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control. RESULTS There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance. CONCLUSIONS Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes.
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Affiliation(s)
- Casey M Silver
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
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Stephens I, Conroy J, Winter D, Simms C, Bucholc M, Sugrue M. Prophylactic onlay mesh placement techniques for optimal abdominal wall closure: randomized controlled trial in an ex vivo biomechanical model. Br J Surg 2023; 110:568-575. [PMID: 36918293 PMCID: PMC10683942 DOI: 10.1093/bjs/znad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/10/2022] [Accepted: 02/01/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Incisional hernias occur after up to 40 per cent of laparotomies. Recent RCTs have demonstrated the role of prophylactic mesh placement in reducing the risk of developing an incisional hernia. An onlay approach is relatively straightforward; however, a variety of techniques have been described for mesh fixation. The biomechanical properties have not been interrogated extensively to date. METHODS This ex vivo randomized controlled trial using porcine abdominal wall investigated the biomechanical properties of three techniques for prophylactic onlay mesh placement at laparotomy closure. A classical onlay, anchoring onlay, and novel bifid onlay approach were compared with small-bite primary closure. A biomechanical abdominal wall model and ball burst test were used to assess transverse stretch, bursting force, and loading characteristics. RESULTS Mesh placement took an additional 7-15 min compared with standard primary closure. All techniques performed similarly, with no clearly superior approach. The minimum burst force was 493 N, and the maximum 1053 N. The classical approach had the highest mean burst force (mean(s.d.) 853(152) N). Failure patterns fell into either suture-line or tissue failures. Classical and anchoring techniques provided a second line of defence in the event of primary suture failure, whereas the bifid method demonstrated a more compliant loading curve. All mesh approaches held up at extreme quasistatic loads. CONCLUSION Subtle differences in biomechanical properties highlight the strengths of each closure type and suggest possible uses. The failure mechanisms seen here support the known hypotheses for early fascial dehiscence. The influence of dynamic loading needs to be investigated further in future studies.
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Affiliation(s)
- Ian Stephens
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Jack Conroy
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
- Trinity Centre for Bioengineering, Department of Mechanical, Manufacturing and Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Des Winter
- Department of Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Ciaran Simms
- Trinity Centre for Bioengineering, Department of Mechanical, Manufacturing and Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Magda Bucholc
- EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Derry-Londonderry, UK
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
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Badia JM, Arroyo-Garcia N, Vázquez A, Almendral A, Gomila-Grange A, Fraccalvieri D, Parés D, Abad-Torrent A, Pascual M, Solís-Peña A, Puig-Asensio M, Pera M, Gudiol F, Limón E, Pujol M. Leveraging a nationwide infection surveillance program to implement a colorectal surgical site infection reduction bundle: a pragmatic, prospective, and multicenter cohort study. Int J Surg 2023; 109:737-751. [PMID: 36917127 PMCID: PMC10389383 DOI: 10.1097/js9.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/26/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Bundled interventions usually reduce surgical site infection (SSI) when implemented at single hospitals, but the feasibility of their implementation at the nationwide level and their clinical results are not well established. MATERIALS AND METHODS Pragmatic interventional study to analyze the implementation and outcomes of a colorectal surgery care bundle within a nationwide quality improvement program. The bundle consisted of antibiotic prophylaxis, oral antibiotic prophylaxis (OAP), mechanical bowel preparation, laparoscopy, normothermia, and a wound retractor. Control group (CG) and Intervention group (IG) were compared. Overall SSI, superficial (S-SSI), deep (D-SSI), and organ/space (O/S-SSI) rates were analyzed. Secondary endpoints included microbiology, 30-day mortality, and length of hospital stay. RESULTS A total of 37 849 procedures were included, 19 655 in the CG and 18 194 in the IG. In all, 5462 SSIs (14.43%) were detected: 1767 S-SSI (4.67%), 847 D-SSI (2.24%), and 2838 O/S-SSI (7.5%). Overall SSI fell from 18.38% (CG) to 10.17% (IG), odds ratio (OR) of 0.503 [0.473-0.524]. O/S-SSI rates were 9.15% (CG) and 5.72% (IG), OR of 0.602 [0.556-0.652]. The overall SSI rate was 16.71% when no measure was applied and 6.23% when all six were used. Bundle implementation reduced the probability of overall SSI (OR: 0.331; CI 95 : 0.242-0.453), and also O/S-SSI rate (OR: 0.643; CI 95 : 0.416-0.919). In the univariate analysis, all measures except normothermia were associated with a reduction in overall SSI, while only laparoscopy, OAP, and mechanical bowel preparation were related to a decrease in O/S-SSI. Laparoscopy, wound retractor, and OAP decreased overall SSI and O/S-SSI in the multivariate analysis. CONCLUSIONS In this cohort study, the application of a specific care bundle within a nationwide nosocomial infection surveillance system proved feasible and resulted in a significant reduction in overall and O/S-SSI rates in the elective colon and rectal surgery. The OR for SSI fell between 1.5 and 3 times after the implementation of the bundle.
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Affiliation(s)
- Josep M. Badia
- Department of Surgery, Hospital General de Granollers, Granollers
- School of Medicine, Universitat Internacional de Catalunya, Sant Cugat del Vallès
| | - Nares Arroyo-Garcia
- Department of Surgery, Hospital General de Granollers, Granollers
- School of Medicine, Universitat Internacional de Catalunya, Sant Cugat del Vallès
| | - Ana Vázquez
- Servei d’Estadística Aplicada, Universitat Autònoma de Barcelona, Bellaterra, Barcelona
| | | | - Aina Gomila-Grange
- Department of Infectious Diseases, Hospital Universitari Parc Taulí, Sabadell
| | - Domenico Fraccalvieri
- Department of Surgery, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat
| | - David Parés
- Colorectal Surgery Unit, Department of Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona
- Universitat Autónoma de Barcelona, Catalonia
| | - Ana Abad-Torrent
- Department of Anaesthesiology, Hospital Universitari Vall d’Hebrón
| | | | | | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid
| | | | | | - Enric Limón
- VINCat Program, Catalonia
- Universitat de Barcelona
| | - Miquel Pujol
- VINCat Program, Catalonia
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid
- Department of Infectious Diseases, Hospital Universitari de Bellvitge
- IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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Mazuski JE, Symons WJ, Jarman S, Sato B, Carroll W, Bochicchio GV, Kirby JP, Schuerer DJ. Reduction of Surgical Site Infection After Trauma Laparotomy Through Use of a Specific Protocol for Antibiotic Prophylaxis. Surg Infect (Larchmt) 2023; 24:141-157. [PMID: 36856586 PMCID: PMC9983134 DOI: 10.1089/sur.2022.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Background: Emergency laparotomy for abdominal trauma is associated with high rates of surgical site infection (SSI). A protocol for antimicrobial prophylaxis (AMP) for trauma laparotomy was implemented to determine whether SSI could be reduced by adhering to established principles of AMP. Patients and Methods: A protocol utilizing ertapenem administered immediately before initiation of trauma laparotomy was adopted. Compliance with measures of adequate AMP were determined before and after protocol implementation, as were rates of SSI and other infections related to abdominal trauma. Univariable and multivariable analyses were performed to determine risk factors for development of infection related to trauma laparotomy. Results: Over a four-year period, 320 patient operations were reviewed. Ertapenem use for prophylaxis increased to 54% in the post-intervention cohort. Compliance with individual measures of appropriate AMP improved modestly. Overall, infections related to trauma laparotomy decreased by 46% (absolute decrease of 13%) in the post-intervention cohort. Multivariable analysis confirmed that treatment during the post-intervention phase was associated with this decrease, with a separate analysis suggesting that ertapenem use was an important factor in this decrease. Conclusions: Development of a standardized protocol for AMP in trauma laparotomy led to decreases in infectious complications after that procedure.
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Affiliation(s)
- John E. Mazuski
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA.,Address correspondence to: Dr. John E. Mazuski, Department of Surgery, Washington University in Saint Louis School of Medicine, Campus Box 8109, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - William J. Symons
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen Jarman
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - Bryan Sato
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - William Carroll
- Trauma Department, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Grant V. Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - John P. Kirby
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - Douglas J. Schuerer
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
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Bilimoria KY, McGee MF, Williams MV, Johnson JK, Halverson AL, O’Leary KJ, Farrell P, Thomas J, Love R, Kreutzer L, Dahlke AR, D’Orazio B, Reinhart S, Dienes K, Schumacher M, Shan Y, Quinn C, Prachand VN, Sullivan S, Cradock KA, Boyd K, Hopkinson W, Fairman C, Odell D, Stulberg JJ, Barnard C, Holl J, Merkow RP, Yang AD. Development of the Illinois Surgical Quality Improvement Collaborative (ISQIC): Implementing 21 Components to Catalyze Statewide Improvement in Surgical Care. Ann Surg Open 2023; 4:e258. [PMID: 36891561 PMCID: PMC9987591 DOI: 10.1097/as9.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/09/2023] [Indexed: 03/05/2023] Open
Abstract
INTRODUCTION In 2014, 56 Illinois hospitals came together to form a unique learning collaborative, the Illinois Surgical Quality Improvement Collaborative (ISQIC). Our objectives are to provide an overview of the first three years of ISQIC focused on (1) how the collaborative was formed and funded, (2) the 21 strategies implemented to support quality improvement (QI), (3) collaborative sustainment, and (4) how the collaborative acts as a platform for innovative QI research. METHODS ISQIC includes 21 components to facilitate QI that target the hospital, the surgical QI team, and the peri-operative microsystem. The components were developed from available evidence, a detailed needs assessment of the hospitals, reviewing experiences from prior surgical and non-surgical QI Collaboratives, and interviews with QI experts. The components comprise 5 domains: guided implementation (e.g., mentors, coaches, statewide QI projects), education (e.g., process improvement (PI) curriculum), hospital- and surgeon-level comparative performance reports (e.g., process, outcomes, costs), networking (e.g., forums to share QI experiences and best practices), and funding (e.g., for the overall program, pilot grants, and bonus payments for improvement). RESULTS Through implementation of the 21 novel ISQIC components, hospitals were equipped to use their data to successfully implement QI initiatives and improve care. Formal (QI/PI) training, mentoring, and coaching were undertaken by the hospitals as they worked to implement solutions. Hospitals received funding for the program and were able to work together on statewide quality initiatives. Lessons learned at one hospital were shared with all participating hospitals through conferences, webinars, and toolkits to facilitate learning from each other with a common goal of making care better and safer for the surgical patient in Illinois. Over the first three years, surgical outcomes improved in Illinois. DISCUSSION The first three years of ISQIC improved care for surgical patients across Illinois and allowed hospitals to see the value of participating in a surgical QI learning collaborative without having to make the initial financial investment themselves. Given the strong support and buy-in from the hospitals, ISQIC has continued beyond the initial three years and continues to support QI across Illinois hospitals.
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Affiliation(s)
- Karl Y. Bilimoria
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael F. McGee
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Mark V. Williams
- Department of Internal Medicine at Washington University St. Louis, St. Louis, MO
| | - Julie K. Johnson
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Amy L. Halverson
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Kevin J. O’Leary
- Division of Medicine-Hospital Medicine, Feinberg School of Medicine Northwestern University, Chicago, IL
| | - Paula Farrell
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Juliana Thomas
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Remi Love
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Lindsey Kreutzer
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Allison R. Dahlke
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Brianna D’Orazio
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Steven Reinhart
- Department of Process Improvement, Northwestern Medicine, Chicago, IL
| | - Katelyn Dienes
- Department of Process Improvement, Northwestern Medicine, Chicago, IL
| | - Mark Schumacher
- Department of Process Improvement, Northwestern Medicine, Chicago, IL
| | - Ying Shan
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Christopher Quinn
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | | | - Susan Sullivan
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | | | - Kelsi Boyd
- Department of General Surgery, Carle Health, Urbana, IL
| | - William Hopkinson
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL
| | - Colleen Fairman
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL
| | - David Odell
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jonah J. Stulberg
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
| | - Cindy Barnard
- Department of Quality Strategies, Northwestern Medicine, Chicago, IL
| | - Jane Holl
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Ryan P. Merkow
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Anthony D. Yang
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC) Coordinating Center, Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Hasegawa T, Tashiro S, Mihara T, Kon J, Sakurai K, Tanaka Y, Morita T, Enoki Y, Taguchi K, Matsumoto K, Nakajima K, Takesue Y. Efficacy of surgical skin preparation with chlorhexidine in alcohol according to the concentration required to prevent surgical site infection: meta-analysis. BJS Open 2022; 6:6704885. [PMID: 36124902 PMCID: PMC9487656 DOI: 10.1093/bjsopen/zrac111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background A combination of chlorhexidine gluconate and alcohol (CHG–alcohol) is recommended for surgical skin preparation to prevent surgical site infection (SSI). Although more than 1 per cent CHG–alcohol is recommended to prevent catheter-related bloodstream infections, there is no consensus regarding the concentration of the CHG compound for the prevention of SSI. Methods A systematic review and meta-analysis was performed. Four electronic databases were searched on 5 November 2020. SSI rates were compared between CHG–alcohol and povidone-iodine (PVP-I) according to the concentration of CHG (0.5 per cent, 2.0 per cent, 2.5 per cent, and 4.0 per cent). Results In total, 106 of 2716 screened articles were retrieved for full-text review. The risk ratios (RRs) of SSI for 0.5 per cent (6 studies) and 2.0 per cent (4 studies) CHG–alcohol were significantly lower than those for PVP-I (RR = 0.71, 95 per cent confidence interval (c.i.) 0.52 to 0.97; RR = 0.52, 95 per cent c.i 0.31 to 0.86 respectively); however, no significant difference was observed in the compounds with a CHG concentration of more than 2.0 per cent. Conclusions This meta-analysis is the first study that clarifies the usefulness of an alcohol-based CHG solution with a 0.5 per cent or higher CHG concentration for surgical skin preparation to prevent SSI.
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Affiliation(s)
- Tatsuki Hasegawa
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Sho Tashiro
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Takayuki Mihara
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Junya Kon
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Kazuki Sakurai
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Yoko Tanaka
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Takumi Morita
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy , Minato-ku, Tokyo , Japan
| | - Kazuhiko Nakajima
- Department of Infection Prevention and Control, Hyogo College of Medicine , Nishinomiya, Hyogo , Japan
| | - Yoshio Takesue
- Department of Infection Prevention and Control, Hyogo College of Medicine , Nishinomiya, Hyogo , Japan
- Department of Clinical Infectious Diseases, Tokoname City Hospital , Tokoname, Aichi , Japan
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Schlick CJR, Huang R, Brajcich BC, Halverson AL, Yang AD, Kreutzer L, Bilimoria KY, McGee MF. Unbundling Bundles: Evaluating the Association of Individual Colorectal Surgical Site Infection Reduction Bundle Elements on Infection Rates in a Statewide Collaborative. Dis Colon Rectum 2022; 65:1052-1061. [PMID: 34840291 PMCID: PMC9124224 DOI: 10.1097/dcr.0000000000002223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical site infection reduction bundles are effective but can be complex and resource intensive. Understanding which bundle elements are associated with reduced surgical site infections may guide concise bundle implementation. OBJECTIVE The purpose of this study was to evaluate the association of individual surgical site infection reduction bundle elements with infection rates. DESIGN This was a post-hoc analysis of a prospective cohort study. SETTING This study took place at Illinois Surgical Quality Improvement Collaborative hospitals. PATIENTS Patients who had elective colorectal resections at participating hospitals from 2016 to 2017. INTERVENTIONS The intervention was a 16-element colorectal surgical site infection reduction bundle. MAIN OUTCOME MEASURES Surgical site infection rates were compared among patients by adherence with each bundle element using χ 2 tests and multivariable logistic regression. Principal component analysis identified composites of correlated bundle elements. Coincidence analysis identified combinations of bundle elements or principal component composites associated with the absence of surgical site infection. RESULTS Among 2722 patients, 192 (7.1%) developed a surgical site infection. Infections were less likely when oral antibiotics (OR 0.63 [95% CI 0.41-0.97]), wound protectors (OR 0.55 [95% CI 0.37-0.81]), and occlusive dressings (OR 0.71 [95% CI 0.51-1.00]) were used. Bundle elements were reduced into 5 principal component composites. Adherence with the combination of oral antibiotics, wound protector, or redosing intravenous antibiotic prophylaxis plus chlorhexidine-alcohol intraoperative skin preparation was associated with the absence of infection (consistency = 0.94, coverage = 0.96). Four of the 5 principal component composites in various combinations were associated with the absence of surgical site infection, whereas the composite consisting of occlusive dressing placement, postoperative dressing removal, and daily postoperative chlorhexidine incisional cleansing had no association with the outcome. LIMITATIONS The inclusion of hospitals engaged in quality improvement initiatives may limit the generalizability of these data. CONCLUSION Bundle elements had varying association with infection reduction. Implementation of colorectal surgical site infection reduction bundles should focus on the specific elements associated with low surgical site infections. See Video Abstract at http://links.lww.com/DCR/B808 . DESEMPAQUETANDO PAQUETES EVALUACIN DE LA ASOCIACIN DE ELEMENTOS INDIVIDUALES DEL PAQUETE DE REDUCCIN DE INFECCIONES DEL SITIO QUIRRGICO COLORRECTAL CON LAS TASAS DE INFECCIN EN UNA COLABORACIN ESTATAL ANTECEDENTES:Los paquetes de reducción de infecciones del sitio quirúrgico son efectivos pero pueden ser complejos y requieren muchos recursos. Comprender qué elementos del paquete están asociados con la reducción de las infecciones del sitio quirúrgico puede guiar la implementación concisa del paquete.OBJETIVO:Evaluar la asociación de los elementos individuales del paquete de reducción de infecciones del sitio quirúrgico con las tasas de infección.DISEÑO:Análisis post-hoc de un estudio de cohorte prospectivo.ESCENARIO:Hospitales colaborativos para la mejora de la calidad quirúrgica de Illinois.PACIENTES:Resecciones colorrectales electivas en los hospitales participantes entre 2016 y 2017.INTERVENCIONES:Paquete de reducción de infección del sitio quirúrgico colorrectal de 16 elementos.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las tasas de infección del sitio quirúrgico entre los pacientes según la adherencia con cada elemento del paquete mediante pruebas de Chi cuadrado y regresión logística multivariable. El análisis de componentes principales identificó compuestos de elementos de paquete correlacionados. El análisis de coincidencia identificó combinaciones de elementos del haz o compuestos de componentes principales asociados con la ausencia de infección del sitio quirúrgico.RESULTADOS:Entre 2722 pacientes, 192 (7,1%) desarrollaron una infección del sitio quirúrgico. Las infecciones fueron menos probables cuando se administraron antibióticos orales (OR 0,63 (IC 95% 0,41-0,97)), protectores de heridas (OR 0,55 (IC 95% 0,37-0,81)) y vendajes oclusivos (OR 0.71 (IC 95% 0,51-1,00]) fueron usados. Los elementos del paquete se redujeron a 5 grupos de componentes principales. La adherencia a la combinación de (1) antibióticos orales, (2) protector de heridas o (3) redosificación de profilaxis antibiótica intravenosa más preparación de la piel intraoperatoria con clorhexidina-alcohol se asoció con la ausencia de infección (consistencia = 0,94, cobertura = 0,96). Cuatro de los cinco grupos de componentes principales en varias combinaciones se asociaron con la ausencia de infección del sitio quirúrgico, mientras que el grupo que consiste en la colocación del apósito oclusivo, la remosión del apósito en posoperatorio y la limpieza incisional posoperatoria diaria con clorhexidina no tuvo asociación con el resultado.LIMITACIONES:La inclusión de hospitales que participan en iniciativas de mejora de la calidad puede limitar la generalización de estos datos.CONCLUSIONES:Los elementos del paquete tuvieron una asociación variable con la reducción de la infección. La implementación de paquetes de reducción de infecciones del sitio quirúrgico colorrectal debe centrarse en los elementos específicos asociados con pocas infecciones del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B808 . (Traducción-Juan Carlos Reyes ).
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Affiliation(s)
- Cary Jo R. Schlick
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Reiping Huang
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Brian C. Brajcich
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Amy L. Halverson
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Anthony D. Yang
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Lindsey Kreutzer
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Karl Y. Bilimoria
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
- Center for Healthcare Studies, Institute for Public Health
and Medicine, Feinberg School of Medicine, Northwestern University, Chicago,
Illinois
| | - Michael F. McGee
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
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11
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Brajcich BC, Schlick CJR, Halverson AL, Huang R, Yang AD, Love R, Bilimoria KY, McGee MF. Association between Patient and Hospital Characteristics and Adherence to a Surgical Site Infection Reduction Bundle in a Statewide Surgical Quality Improvement Collaborative. J Am Coll Surg 2022; 234:783-792. [PMID: 35426391 DOI: 10.1097/xcs.0000000000000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adherence to bundled interventions can reduce surgical site infection (SSI) rates; however, predictors of successful implementation are poorly characterized. We studied the association of patient and hospital characteristics with adherence to a colorectal SSI reduction bundle across a statewide surgical collaborative. STUDY DESIGN A 16-component colorectal SSI reduction bundle was introduced in 2016 across a statewide quality improvement collaborative. Bundle adherence was measured for patients who underwent colorectal operations at participating institutions. Multivariable mixed-effects logistic regression models were constructed to estimate associations of patient and hospital factors with bundle adherence and quantify sources of variation. RESULTS Among 2,403 patients at 35 hospitals, a median of 11 of 16 (68.8%, interquartile range 8 to 13) bundle elements were completed. The likelihood of completing 11 or more elements was increased for obese patients (56.8% vs 51.5%, odds ratio [OR] 1.39, 95% CI 1.05 to 1.86, p = 0.022) but reduced for underweight patients (31.0% vs 51.5%, OR 0.51, 95% CI 0.26 to 1.00, p = 0.048) compared with patients with a normal BMI. Lower adherence was noted for patients treated at safety net hospitals (n = 9 hospitals, 24.4% vs 54.4%, OR 0.08, 95% CI 0.01 to 0.44, p = 0.004). The largest proportion of adherence variation was attributable to hospital factors for six bundle elements, surgeon factors for no elements, and patient factors for nine elements. CONCLUSION Adherence to an SSI reduction bundle is associated with patient BMI and hospital safety net status. Quality improvement groups should consider institutional traits for optimal implementation of SSI bundles. Safety net hospitals may require additional focus to overcome unique implementation barriers.
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Affiliation(s)
- Brian C Brajcich
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Cary Jo R Schlick
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Amy L Halverson
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Reiping Huang
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Anthony D Yang
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Remi Love
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Karl Y Bilimoria
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Michael F McGee
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
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12
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Shi Z, Hon J, Cheng C, Chiang H, Huang H. Applying Machine Learning Techniques to the Audit of Antimicrobial Prophylaxis. Applied Sciences 2022; 12:2586. [DOI: 10.3390/app12052586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High rates of inappropriate use of surgical antimicrobial prophylaxis were reported in many countries. Auditing the prophylactic antimicrobial use in enormous medical records by manual review is labor-intensive and time-consuming. The purpose of this study is to develop accurate and efficient machine learning models for auditing appropriate surgical antimicrobial prophylaxis. The supervised machine learning classifiers (Auto-WEKA, multilayer perceptron, decision tree, SimpleLogistic, Bagging, and AdaBoost) were applied to an antimicrobial prophylaxis dataset, which contained 601 instances with 26 attributes. Multilayer perceptron, SimpleLogistic selected by Auto-WEKA, and decision tree algorithms had outstanding discrimination with weighted average AUC > 0.97. The Bagging and SMOTE algorithms could improve the predictive performance of decision tree against imbalanced datasets. Although with better performance measures, multilayer perceptron and Auto-WEKA took more execution time as compared with that of other algorithms. Multilayer perceptron, SimpleLogistic, and decision tree algorithms have outstanding performance measures for identifying the appropriateness of surgical prophylaxis. The efficient models developed by machine learning can be used to assist the antimicrobial stewardship team in the audit of surgical antimicrobial prophylaxis. In future research, we still have the challenges and opportunities of enriching our datasets with more useful clinical information to improve the performance of the algorithms.
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Kuwahara R, Uchino M, Ikeuchi H, Bando T, Sasaki H, Yasuhara M, Kimura K, Goto Y, Horio Y, Minagawa T, Ikeda M, Ueda T, Takesue Y. Effect of Changing Surgical Instruments Before Wound Closure to Prevent Wound Infection in Lower GI Surgery: A Randomized Controlled Trial. Dis Colon Rectum 2022; 65:100-7. [PMID: 34882632 DOI: 10.1097/DCR.0000000000002035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical site infection is a major surgical complication and has been studied extensively. However, the efficacy of changing surgical instruments before wound closure remains unclear. OBJECTIVE The aim of this study was to investigate the efficacy of changing surgical instruments to prevent incisional surgical site infection during lower GI surgery. DESIGN This was a randomized controlled trial. SETTINGS This study was conducted at the Hyogo College of Medicine in Japan. PATIENTS Patients undergoing elective lower GI surgery with open laparotomy were included. INTERVENTIONS Patients were randomly assigned to 1 of 2 groups. In group A, the surgeon changed surgical instruments before wound closure, and in group B, the patients underwent conventional closure. MAIN OUTCOME MEASURES The primary end point was the incidence of incisional surgical site infection. The secondary end point was the incidence of surgical site infection restricted to clean-contaminated surgery. RESULTS A total of 453 patients were eligible for this trial. The incidence of incisional surgical site infection was not significantly different between group A (18/213; 8.5%) and group B (24/224; 10.7%; p = 0.78). In the clean-contaminated surgery group, the incidence of incisional surgical site infection was 13 (6.8%) of 191 in group A and 9 (4.7%) of 190 in group B (p = 0.51). LIMITATIONS This was a single-center study. CONCLUSIONS Changing surgical instruments did not decrease the rate of incisional surgical site infection in patients undergoing lower GI surgery in either all wound classes or clean-contaminated conditions. See Video Abstract at http://links.lww.com/DCR/B701. EFECTO DE REALIZAR CAMBIO DE LOS INSTRUMENTOS QUIRRGICOS ANTES DEL CIERRE DE LA INCISIN EN LA INFECCIN DE LA HERIDA DEL SITIO QUIRRGICO EN CIRUGA DEL TUBO DIGESTIVO BAJO ESTUDIO ALEATORIO CONTROLADO ANTECEDENTES:La infección del sitio quirúrgico es una complicación importante y se ha estudiado ampliamente. Sin embargo, la eficacia de cambiar los instrumentos quirúrgicos antes del cierre de la herida sigue sin estar clara.OBJETIVO:El objetivo de este estudio es investigar la eficacia de cambiar el instrumental quirúrgico en la prevención de la infección del sitio quirúrgico en cirugía gastrointestinal inferior.DISEÑO:Estudio aleatorio controlado.AJUSTE:Este estudio se realizó en la Facultad de Medicina de Hyogo en Japón.PACIENTES:Se incluyeron pacientes sometidos a cirugía electiva de tubo digestivo bajo con laparotomía abierta.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente a uno de dos grupos. En el grupo A, el cirujano cambió el instrumental quirúrgico antes del cierre de la herida, y en el grupo B, los pacientes se sometieron a un cierre convencional.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la incidencia de infección del sitio quirúrgico de la incisión. El criterio de valoración secundario fue la incidencia de infección del sitio quirúrgico restringida a la cirugía limpia contaminada.RESULTADOS:Un total de 453 pacientes fueron elegibles para este ensayo. La incidencia de infección del sitio quirúrgico no fue significativamente diferente entre el grupo A (18/213; 8,5%) y el grupo B (24/224; 10,7%) (p = 0,78). En el grupo de cirugía limpia-contaminada, la incidencia de infección del sitio quirúrgico incisional fue 13/191 (6,8%) en el grupo A y 9/190 (4,7%) en el grupo B (p = 0,51).LIMITACIÓN:Estudio de un solo centro.CONCLUSIÓNES:El cambio de instrumentos quirúrgicos no disminuyó la tasa de infección del sitio quirúrgico en todas las clases de heridas o condiciones limpias-contaminadas. Consulte Video Resumen en http://links.lww.com/DCR/B701.
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Ghuman A, Karimuddin AA, Brown CJ, Raval MJ, Phang PT. Colorectal surgery surgical site infection prevention practices in British Columbia. Can J Surg 2021; 64:E516-E520. [PMID: 34598929 PMCID: PMC8526141 DOI: 10.1503/cjs.007220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 11/08/2022] Open
Abstract
Surgical site infections (SSI) pose significant morbidity after colorectal surgery. We sought to document current practices in colorectal surgery SSI prevention in British Columbia (BC). Reporting the current provincial landscape on SSI prevention helps to understand the foundation upon which improvements can take place. We surveyed all BC surgeons performing elective colon and rectal resections, and 97 surveys were completed (60% response rate). Eighty-six per cent of respondent hospitals tracked SSI rates. The reported superficial SSI was less than 5% and the anastomotic leak/organ space rate was less than 10%. All respondents gave preoperative prophylactic antibiotics, with 24% continuing antibiotics postoperatively; 62% are using oral antibiotics (OAB) and mechanical bowel preparation (MBP) and 29% use MBP without OAB. Areas for improvement include OAB with MBP and discontinuing prophylactic antibiotics postoperatively, as recommended by the World Health Organization.
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Affiliation(s)
- Amandeep Ghuman
- From the Department of Surgery, Division of General Surgery, University of British Columbia, Vancouver, BC (Ghuman); and the Department of Surgery, St. Paul's Hospital, Vancouver, BC (Karimuddin, Brown, Raval, Phang)
| | - Ahmer A Karimuddin
- From the Department of Surgery, Division of General Surgery, University of British Columbia, Vancouver, BC (Ghuman); and the Department of Surgery, St. Paul's Hospital, Vancouver, BC (Karimuddin, Brown, Raval, Phang)
| | - Carl J Brown
- From the Department of Surgery, Division of General Surgery, University of British Columbia, Vancouver, BC (Ghuman); and the Department of Surgery, St. Paul's Hospital, Vancouver, BC (Karimuddin, Brown, Raval, Phang)
| | - Manoj J Raval
- From the Department of Surgery, Division of General Surgery, University of British Columbia, Vancouver, BC (Ghuman); and the Department of Surgery, St. Paul's Hospital, Vancouver, BC (Karimuddin, Brown, Raval, Phang)
| | - P Terry Phang
- From the Department of Surgery, Division of General Surgery, University of British Columbia, Vancouver, BC (Ghuman); and the Department of Surgery, St. Paul's Hospital, Vancouver, BC (Karimuddin, Brown, Raval, Phang)
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Dellinger EP, Villaflor-Camagong D, Whimbey E. Gradually Increasing Surgical Site Infection Prevention Bundle with Monitoring of Potentially Preventable Infections Resulting in Decreasing Overall Surgical Site Infection Rate. Surg Infect (Larchmt) 2021; 22:1072-1076. [PMID: 34382872 DOI: 10.1089/sur.2021.183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective: Reduction of surgical site infection. Methods: Retrospective evaluation of a surgical infection prevention program consisting of the gradual introduction of specific infection prevention methods and a surveillance system identifying and reporting on potentially preventable surgical site infections as defined by the omission of a preventive method. Setting: A university tertiary referral medical center. Results: The sequential introduction of infection prevention elements in the bundle resulted in a fluctuating rate of potentially preventable surgical site infections simultaneously with a slow, gradual reduction of the clean wound SSI rate. Conclusions: Change in a complex, multidisciplinary environment such as an inpatient surgical unit happens gradually and requires focused attention and input from all involved professionals.
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Affiliation(s)
- E Patchen Dellinger
- Department of Surgery, University of Washington, University of Washington Medical Center, Seattle, Washington, USA
| | | | - Estella Whimbey
- University of Washington, Department of Medicine: Allergy and Infectious Diseases, University of Washington Medical Center, Seattle, Washington, USA
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Jackson TD, Beath T, Ahmad N, Arsenault PP, Maeda A, Schramm D, Moloo H, Nathens A. Committed to Better Outcomes: Reducing Infection after Surgery Across the Ontario Surgical Quality Improvement Network. J Am Coll Surg 2021; 233:204-211. [PMID: 34015457 DOI: 10.1016/j.jamcollsurg.2021.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In 2015, the Ontario Surgical Quality Improvement Network was established to create a community of practice for Ontario hospitals to improve surgical quality. A provincial campaign to decrease postsurgical infections was launched in 2017. STUDY DESIGN Thirty hospitals implemented activities related to the campaign from April 2018 to March 2019. The community of practice was used to disseminate suggested change ideas in each area. Self-reported data from participating hospitals and collaborative-wide aggregate risk-adjusted data from the American College of Surgeons NSQIP were reviewed to determine the impact of the campaign on the rates of postoperative surgical site infections (SSIs), urinary tract infections (UTIs), and pneumonia. RESULTS A total of 24, 8, and 2 hospitals selected SSIs, UTIs, and pneumonia, respectively, as their targets for improvement. Three hospitals selected both SSIs and UTIs, 1 hospital selected SSIs and pneumonia, and 1 hospital selected all 3 indicators as targets. Self-reported data demonstrated that the rates of SSIs and UTIs decreased significantly post campaign from 4.87% to 3.99% (p < 0.0001) and from 3.65% to 1.25% (p = 0.007), respectively. Pneumonia rates also decreased from 1.27% to 1.05%. Overall rates of SSIs, UTIs, and pneumonia across all Ontario Surgical Quality Improvement Network hospitals were reduced from 3.4%, 1.29%, and 0.88% to 3.37%, 1.14%, and 0.84%, respectively. CONCLUSIONS The 1-year campaign resulted in a clinically significant reduction in the rates of SSIs and UTIs, as well as a trend for decrease in pneumonia incidence among participating hospitals. Using a flexible approach with priority setting and leveraging the community of practice for dissemination of change ideas is an effective way of sustaining quality improvement activities.
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Affiliation(s)
- Timothy D Jackson
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
| | | | | | | | - Azusa Maeda
- Division of General Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - David Schramm
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Husein Moloo
- Division of General Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Canada; Division of General Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Avery Nathens
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of HEalth Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Bucher BT, Shi J, Ferraro JP, Skarda DE, Samore MH, Hurdle JF, Gundlapalli AV, Chapman WW, Finlayson SRG. Portable Automated Surveillance of Surgical Site Infections Using Natural Language Processing: Development and Validation. Ann Surg 2020; 272:629-36. [DOI: 10.1097/sla.0000000000004133] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Alverdy JC, Hyman N, Gilbert J. Re-examining causes of surgical site infections following elective surgery in the era of asepsis. Lancet Infect Dis 2020; 20:e38-e43. [PMID: 32006469 DOI: 10.1016/s1473-3099(19)30756-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 11/29/2019] [Accepted: 12/20/2019] [Indexed: 02/07/2023]
Abstract
The currently accepted assumption that most surgical site infections (SSIs) occurring after elective surgery under standard methods of antisepsis are due to an intraoperative contamination event, remains unproven. We examined the available evidence in which microbial cultures of surgical wounds were taken at the conclusion of an operation and determined that such studies provide more evidence to refute that an SSI is due to intraoperative contamination than support it. We propose that alternative mechanisms of SSI development should be considered, such as when a sterile postoperative wound becomes infected by a pathogen originating from a site remote from the operative wound-eg, from the gums or intestinal tract (ie, the Trojan Horse mechanism). We offer a path forward to reduce SSI rates after elective surgery that includes undertaking genomic-based microbial tracking from the built environment (ie, the operating room and hospital bed), to the patient's own microbiome, and then to the surgical site. Finally, we posit that only by generating this dynamic microbial map can the true pathogenesis of SSIs be understood enough to inform novel preventive strategies against infection following elective surgery in the current era of asepsis.
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Affiliation(s)
- John C Alverdy
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA.
| | - Neil Hyman
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jack Gilbert
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
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