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.

Surveillance of Surgical Site Infections following Major Hip and Knee Surgery in Finland

Background and aims. Since 1999, hospitals in the Finnish Hospital Infection Program (SIRO) have reported data on surgical site infections (SSI) following major hip and knee surgery. The purpose of this study was to obtain detailed information to support prevention efforts by analyzing SIRO data on SSIs, to evaluate possible factors affecting the surveillance results, and to assess the disease burden of postoperative prosthetic joint infections in Finland. Methods. Procedures under surveillance included total hip (THA) and total knee arthroplasties (TKA), and the open reduction and internal fixation (ORIF) of femur fractures. Hospitals prospectively collected data using common definitions and written protocol, and also performed postdischarge surveillance. In the validation study, a blinded retrospective chart review was performed and infection control nurses were interviewed. Patient charts of deep incisional and organ/space SSIs were reviewed, and data from three sources (SIRO, the Finnish Arthroplasty Register, and the Finnish Patient Insurance Centre) were linked for capture-recapture analyses. Results. During 1999-2002, the overall SSI rate was 3.3% after 11,812 orthopedic procedures (median length of stay, eight days). Of all SSIs, 56% were detected after discharge. The majority of deep incisional and organ/space SSIs (65/108, 60%) were detected on readmission. Positive and negative predictive values, sensitivity, and specificity for SIRO surveillance were 94% (95% CI, 89-99%), 99% (99-100%), 75% (56-93%), and 100% (97-100%), respectively. Of the 9,831 total joint replacements performed during 2001-2004, 7.2% (THA 5.2% and TKA 9.9%) of the implants were inserted in a simultaneous bilateral operation. Patients who underwent bilateral operations were younger, healthier, and more often males than those who underwent unilateral procedures. The rates of deep SSIs or mortality did not differ between bi- and uni-lateral THAs or TKAs. Four deep SSIs were reported following bilateral operations (antimicrobial prophylaxis administered 48-218 minutes before incision). In the three registers, altogether 129 prosthetic joint infections were identified after 13,482 THA and TKA during 1999-2004. After correction with the positive predictive value of SIRO (91%), a log-linear model provided an estimated overall prosthetic joint infection rate of 1.6% after THA and 1.3% after TKA. The sensitivity of the SIRO surveillance ranged from 36% to 57%. According to the estimation, nearly 200 prosthetic joint infections could occur in Finland each year (the average from 1999 to 2004) after THA and TKA. Conclusions. Postdischarge surveillance had a major impact on SSI rates after major hip and knee surgery. A minority of deep incisional and organ/space SSIs would be missed, however, if postdischarge surveillance by questionnaire was not performed. According to the validation study, most SSIs reported to SIRO were true infections. Some SSIs were missed, revealing some weakness in case finding. Variation in diagnostic practices may also affect SSI rates. No differences were found in deep SSI rates or mortality between bi- and unilateral THA and TKA. However, patient materials between these two groups differed. Bilateral operations require specific attention paid to their antimicrobial prophylaxis as well as to data management in the surveillance database. The true disease burden of prosthetic joint infections may be heavier than the rates from national nosocomial surveillance systems usually suggest.

Predictive factors of post-discharge surgical site infections among patients from a teaching hospital

Introduction Surgical site infections (SSIs) often manifest after patients are discharged and are missed by hospital-based surveillance. Methods We conducted a case-reference study nested in a prospective cohort of patients from six surgical specialties in a teaching hospital. The factors related to SSI were compared for cases identified during the hospital stay and after discharge. Results Among 3,427 patients, 222 (6.4%) acquired an SSI. In 138 of these patients, the onset of the SSI occurred after discharge. Neurological surgery and the use of steroids were independently associated with a greater likelihood of SSI diagnosis during the hospital stay. Conclusions Our results support the idea of a specialty-based strategy for post-discharge SSI surveillance.

Prevention and control of surgical site infections: review of the Basel Cohort Study

INTRODUCTION: Surgical site infections (SSI) are the most common hospital-acquired infections among surgical patients, with significant impact on patient morbidity and health care costs. The Basel SSI Cohort Study was performed to evaluate risk factors and validate current preventive measures for SSI. The objective of the present article was to review the main results of this study and its implications for clinical practice and future research. SUMMARY OF METHODS OF THE BASEL SSI COHORT STUDY: The prospective observational cohort study included 6,283 consecutive general surgery procedures closely monitored for evidence of SSI up to 1 year after surgery. The dataset was analysed for the influence of various potential SSI risk factors, including timing of surgical antimicrobial prophylaxis (SAP), glove perforation, anaemia, transfusion and tutorial assistance, using multiple logistic regression analyses. In addition, post hoc analyses were performed to assess the economic burden of SSI, the efficiency of the clinical SSI surveillance system, and the spectrum of SSI-causing pathogens. REVIEW OF MAIN RESULTS OF THE BASEL SSI COHORT STUDY: The overall SSI rate was 4.7% (293/6,283). While SAP was administered in most patients between 44 and 0 minutes before surgical incision, the lowest risk of SSI was recorded when the antibiotics were administered between 74 and 30 minutes before surgery. Glove perforation in the absence of SAP increased the risk of SSI (OR 2.0; CI 1.4-2.8; p <0.001). No significant association was found for anaemia, transfusion and tutorial assistance with the risk of SSI. The mean additional hospital cost in the event of SSI was CHF 19,638 (95% CI, 8,492-30,784). The surgical staff documented only 49% of in-hospital SSI; the infection control team registered the remaining 51%. Staphylococcus aureus was the most common SSI-causing pathogen (29% of all SSI with documented microbiology). No case of an antimicrobial-resistant pathogen was identified in this series. CONCLUSIONS: The Basel SSI Cohort Study suggested that SAP should be administered between 74 and 30 minutes before surgery. Due to the observational nature of these data, corroboration is planned in a randomized controlled trial, which is supported by the Swiss National Science Foundation. Routine change of gloves or double gloving is recommended in the absence of SAP. Anaemia, transfusion and tutorial assistance do not increase the risk of SSI. The substantial economic burden of in-hospital SSI has been confirmed. SSI surveillance by the surgical staff detected only half of all in-hospital SSI, which prompted the introduction of an electronic SSI surveillance system at the University Hospital of Basel and the Cantonal Hospital of Aarau. Due to the absence of multiresistant SSI-causing pathogens, the continuous use of single-shot single-drug SAP with cefuroxime (plus metronidazole in colorectal surgery) has been validated.

Economic burden of surgical site infections at a European university hospital

OBJECTIVE: To quantify the economic burden of in-hospital surgical site infections (SSIs) at a European university hospital. DESIGN: Matched case-control study nested in a prospective observational cohort study. SETTING: Basel University Hospital in Switzerland, where an average of 28,000 surgical procedures are performed per year. METHODS: All in-hospital occurrences of SSI associated with surgeries performed between January 1, 2000, and December 31, 2001, by the visceral, vascular, and traumatology divisions at Basel University Hospital were prospectively recorded. Each case patient was matched to a control patient by age, procedure code, and National Nosocomial Infection Surveillance System risk index. The case-control pairs were analyzed for differences in cost of hospital care and in provision of specialized care. RESULTS: A total of 6,283 procedures were performed: 187 SSIs were detected in inpatients, 168 of whom were successfully matched with a control patient. For case patients, the mean additional hospital cost was SwF-19,638 (95% confidence interval [CI], SwF-8,492-SwF-30,784); the mean additional postoperative length of hospital stay was 16.8 days (95% CI, 13-20.6 days); and the mean additional in-hospital duration of antibiotic therapy was 7.4 days (95% CI, 5.1-9.6 days). Differences were primarily attributable to organ space SSIs (n = 76). CONCLUSIONS: In a European university hospital setting, SSIs are costly and constitute a heavy and potentially preventable burden on both patients and healthcare providers.

Prevalence of surgical wound infection after surgery for breast cancer: systematic review

One of the known risk factors for abuse and neglect of the elderly is the decrease in functionat capacity, contributíng to self care dependency of instrumental actívities of daily living and basic activities of daily Itving (OMS, 2015). Methods: Cross-sectional study with non probabilistíc sample of 333 elderly, performed in a hospital, homes and day centers for the elderly. The data collectíon protocol tncluded socio-demographic data, Questíons to elicit Elder Abuse (Carney, Kahan B Paris, 2003 adap. By Ferreira Alves & Sousa, 2005), scale of instrumental actívi - ties of daily living Lawton and Brody and Katz index to assess the levei of independence in actívities of daily living. Objectives: To evaluate the assodation between abuse and neglect in the elderly, instrumental actívitíes of daily living and levei of independence in actívitíes of daily living. Results: Emotional abuse is signifícantty correlated with the levei of independence in activities of daity Uving (p = 0. 000), older peopie with less independence tend to have higher leveis of emotional abuse. The total abuse is signtficantly correlated with the leveis of independence in activittes of daily living (p = 0. 002), less independent elderty tend to suffer greater abuse and neglect. There were no statistically significant associations between abuse and neglect and instrumental activities of daily l1v1ng. Conclusions: The less independent elderly are more vulnerable to situatíons of abuse and neglect, being more exposed to emotional abuse. These results point to the need for health professionals/ nurses develop prevention interventions, including strategies to support carers and early screentng tn less independent elderly. Keywords: Elder abuse. Negligence. Nursing care. Frail elderly. PREVALENCE OF SURGICAL WOUND INFECTION AFTER SURGERY FOR BREAST CÂNCER: SYSTEMATIC REVIEW C. Amaral3, C. Teixeira"'1', F. Sousa'', C. Antãoa "Polythecnic Institute o f Bragança, Bragança, Portugal; bEPI Unit, Public Health Institute, University of Porto, Portugal. Contact details: catarinaisabeln.amaraliSsmaU.com Introduction: Breast câncer is one of the most common mahgnant pathology in European countries, as Portugal, where annual inddence is around 90 new cases per 100,000 women. Breast surgery is the usual treatment for this pathology, however such procedure can be complicated by the infection of surgical site. Objectives: To know the prevalence and determtnants of surgtcal wound infection after breast surgery. Methods: We conducted a systematic review by searching of the Web of Sdence electronic database for articles published over the last s1x years 1n developed countries. Over three hundred dtatíons were obtained and after excludtng citations with reasons, fíve artícles met our inclusion criteria and were included in the present review. Results: Prevalence of surgical wound infection varied across studies between 0. 1% and 12. 5%. Bilateral mastectomy is assodated with higher prevalence of wound infectíon than unilateral mastectomy (3. 6% vs 3, 3%), lumpectomy with immediate breast reconstruction (IBR) is related with higher frequency of wound infectíon than surgery with no IBR (0, 5% vs 0, 1%), also, mastectomy with IBR is associated with higher prevalence of wound infectíon than mastectomy wtth no IBR (1, 5% vs 0, 3%) and breast surgery followed by axiltary lymph nade dissectíon is related with higher prevalence of wound infection than surgical procedures wtth no axillary lymph node dissection (2, 82% vs 1, 66%). Conclusions: Nurses that provide post-operatíve care to women after breast surgery should be aware about risk of wound tnfectíon, partícularly after more invasive procedures.

The importance of good data, analysis and interpretation for showing the economics of reducing healthcare-associated infection

To the Editor—In a recent review article in Infection Control and Hospital Epidemiology, Umscheid et al1 summarized published data on incidence rates of catheter-associated bloodstream infection (CABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI), and ventilator- associated pneumonia (VAP); estimated how many cases are preventable; and calculated the savings in hospital costs and lives that would result from preventing all preventable cases. Providing these estimates to policy makers, political leaders, and health officials helps to galvanize their support for infection prevention programs. Our concern is that important limitations of the published studies on which Umscheid and colleagues built their findings are incompletely addressed in this review. More attention needs to be drawn to the techniques applied to generate these estimates...

Incidence and predictors of lower limb split-skin graft failure and primary closure dehiscence in day-case surgical patients

BACKGROUND After general surgery, the lower limb experiences some of the highest complication rates. However, little is known about contributing factors to surgical site failure in the lower limb dermatological surgery population. OBJECTIVE To determine the incidence of lower limb surgical site failure and to explore the predictors that contribute to surgical site failure. METHODS A prospective observational study design was used to collect data from 73 participants, from July 2010, to March 2012. Incidence was determined as a percentage of surgical site failure from the total population. Predictors were determined by the use of a binary logistic regression model. RESULTS The surgical site failure rate was 53.4%. Split-skin grafting had a higher failure rate than primary closures, 66% versus 26.1%. Predictors of lower limb surgical site failure were identified as increasing age (p = .04) and the presence of postoperative hematoma (p = .01), with all patients who developed surgical site infection experiencing surgical site failure (p = .01). CONCLUSION Findings from this study confirmed that the lower limb is at high risk of surgical site failure. Two predictors of surgical site failure from this cohort were determined. However, to understand this phenomenon and make recommendations to assist and reduce surgical site complications, further research in this field is required.

Differences in identifying healthcare associated infections using clinical vignettes and the influence of respondent characteristics: A cross-sectional survey of Australian infection prevention staff

Background Australia has commenced public reporting and benchmarking of healthcare associated infections (HAIs), despite not having a standardised national HAI surveillance program. Annual hospital Staphylococcus aureus bloodstream (SAB) infection rates are released online, with other HAIs likely to be reported in the future. Although there are known differences between hospitals in Australian HAI surveillance programs, the effect of these differences on reported HAI rates is not known. Objective To measure the agreement in HAI identification, classification, and calculation of HAI rates, and investigate the influence of differences amongst those undertaking surveillance on these outcomes. Methods A cross-sectional online survey exploring HAI surveillance practices was administered to infection prevention nurses who undertake HAI surveillance. Seven clinical vignettes describing HAI scenarios were included to measure agreement in HAI identification, classification, and calculation of HAI rates. Data on characteristics of respondents was also collected. Three of the vignettes were related to surgical site infection and four to bloodstream infection. Agreement levels for each of the vignettes were calculated. Using the Australian SAB definition, and the National Health and Safety Network definitions for other HAIs, we looked for an association between the proportion of correct answers and the respondents’ characteristics. Results Ninety-two infection prevention nurses responded to the vignettes. One vignette demonstrated 100 % agreement from responders, whilst agreement for the other vignettes varied from 53 to 75 %. Working in a hospital with more than 400 beds, working in a team, and State or Territory was associated with a correct response for two of the vignettes. Those trained in surveillance were more commonly associated with a correct response, whilst those working part-time were less likely to respond correctly. Conclusion These findings reveal the need for further HAI surveillance support for those working part-time and in smaller facilities. It also confirms the need to improve uniformity of HAI surveillance across Australian hospitals, and raises questions on the validity of the current comparing of national HAI SAB rates.

Variation in health care-associated infection surveillance practices in Australia

In the absence of a national health care-associated infection surveillance program in Australia, differences between existing state-based programs were explored using an online survey. Only 51% of respondents who undertake surveillance have been trained, fewer than half perform surgical site infection surveillance prospectively, and only 41% indicated they risk adjust surgical site infection data. Wide- spread variation of surveillance methods highlights future challenges when considering the development and implementation of a national program in Australia.

Variation in the type and frequency of postoperative invasive Staphylococcus aureus infections according to type of surgical procedure.

OBJECTIVE: To determine the epidemiological characteristics of postoperative invasive Staphylococcus aureus infection following 4 types of major surgical procedures.design. Retrospective cohort study. SETTING: Eleven hospitals (9 community hospitals and 2 tertiary care hospitals) in North Carolina and Virginia. PATIENTS: Adults undergoing orthopedic, neurosurgical, cardiothoracic, and plastic surgical procedures. METHODS: We used previously validated, prospectively collected surgical surveillance data for surgical site infection and microbiological data for bloodstream infection. The study period was 2003 through 2006. We defined invasive S. aureus infection as either nonsuperficial incisional surgical site infection or bloodstream infection. Nonparametric bootstrapping was used to generate 95% confidence intervals (CIs). P values were generated using the Pearson chi2 test, Student t test, or Wilcoxon rank-sum test, as appropriate. RESULTS: In total, 81,267 patients underwent 96,455 procedures during the study period. The overall incidence of invasive S. aureus infection was 0.47 infections per 100 procedures (95% CI, 0.43-0.52); 227 (51%) of 446 infections were due to methicillin-resistant S.aureus. Invasive S. aureus infection was more common after cardiothoracic procedures (incidence, 0.79 infections per 100 procedures [95%CI, 0.62-0.97]) than after orthopedic procedures (0.37 infections per 100 procedures [95% CI, 0.32-0.42]), neurosurgical procedures (0.62 infections per 100 procedures [95% CI, 0.53-0.72]), or plastic surgical procedures (0.32 infections per 100 procedures [95% CI, 0.17-0.47]) (P < .001). Similarly, S. aureus bloodstream infection was most common after cardiothoracic procedures (incidence, 0.57 infections per 100 procedures [95% CI, 0.43-0.72]; P < .001, compared with other procedure types), comprising almost three-quarters of the invasive S. aureus infections after these procedures. The highest rate of surgical site infection was observed after neurosurgical procedures (incidence, 0.50 infections per 100 procedures [95% CI, 0.42-0.59]; P < .001, compared with other procedure types), comprising 80% of invasive S.aureus infections after these procedures. CONCLUSION: The frequency and type of postoperative invasive S. aureus infection varied significantly across procedure types. The highest risk procedures, such as cardiothoracic procedures, should be targeted for ongoing preventative interventions.