Implementation methods of infection prevention measures in orthopedics and traumatology - a systematic review

Role of Dithiothreitol in Detection of Orthopaedic Implant-Associated Infections

Orthopaedic implant-associated infections (OIAIs) represent a notable complication of contemporary surgical procedures, exerting a considerable impact on patient outcomes and escalating healthcare expenditures. Prompt diagnosis holds paramount importance in managing OIAIs, with sonication widely acknowledged as the preferred method for detecting biofilm-associated infections. Recently, dithiothreitol (DTT) has emerged as a potential substitute for sonication, owing to its demonstrated ability to impede biofilm formation. This study aimed to compare the efficacy of DTT with sonication in identifying microorganisms within implants. Conducted as a prospective cohort investigation, the study encompassed two distinct groups: patients with suspected infections undergoing implant removal (Group A) and those slated for hardware explantation (Group B). Hardware segments were assessed for biofilm-related microorganisms using both sonication and DTT, with a comparative analysis of the two methods. A total of 115 patients were enrolled. In Group A, no statistically significant disparity was observed between DTT and sonication. DTT exhibited a sensitivity of 89.47% and specificity of 96.3%. Conversely, in Group B, both DTT and sonication fluid cultures yielded negative results in all patients. Consequently, this investigation suggests that DTT holds comparable efficacy to sonication in detecting OIAIs, offering a novel, cost-effective, and readily accessible diagnostic modality for identifying implant-associated infections.

Introduction of a New Protocol to Limit the Number of Cancelled Elective Orthopaedic Operations Due to Asymptomatic Bacteriuria

Background Asymptomatic bacteriuria (ASB) poses a significant diagnostic dilemma for medical professionals. Current hospital screening protocol determines the likelihood of a positive diagnosis of a urinary tract infection (UTI) based on the results of a bedside urinalysis. ASB, defined as a positive urine culture in the absence of symptoms, can contribute to unnecessary cancellations, poor utilisation of theatre time, and delayed patient care. We present a two-cycle audit proposing a new pathway to addressing ASB in patients awaiting elective orthopaedic surgery, aiming to optimise surgical yield. Our objectives are to identify areas for improvement in our departmental practices with respect to asymptomatic bacteria compared to the published literature. We propose a new protocol targeted to improve our current practices to minimise patient cancellations and optimise theatre utilisation. Methodology A total of 78 patients who had an elective orthopaedic procedure cancelled at a large district general hospital offering tertiary orthopaedic services, between two study periods spanning March 2018 to April 2019 and May 2019 to March 2020, were identified from electronic hospital records and theatre management systems. Demographics, procedure details, and reasons for cancellations, including the result of urinalysis and the presence of UTI symptoms were assessed. Our pathway was introduced after the first study period and, subsequently, re-audited to assess adherence to the new protocol and its effect on cancellations. Results We identified 78 patients, with a 50:50 male:female split and an average age of 63 (range = 9-90). Of the 33 patients in the first cohort, seven (21.2%) were cancelled due to UTI risk based on positive urinalysis. Of these seven cancellations, one (14.3%) patient reported symptoms of a UTI. The second cohort comprised 45 patients, two (4.4%) of whom were cancelled due to UTI risk based on symptom questionnaire results. These two symptomatic patients along with another two asymptomatic patients (8.8% in total) were found to have positive urinalyses; however, the two asymptomatic patients had their operations cancelled for unrelated reasons. Conclusions The study has shown that previously of all patients awaiting elective orthopaedic operations who had their procedures cancelled, 85.7% were cancelled due to ASB. After the introduction of a new protocol focussing on symptoms rather than urinalysis, we estimate that the number of cancelled elective orthopaedic operations has reduced by 71.4%, thereby greatly improving the utilisation of theatre time.

Tailoring implementation interventions of different order in infection prevention and control: A cascadic logic model (IPC-CASCADE)

Implementation interventions in infection prevention and control (IPC) differ by recipients. The two target groups are healthcare workers directly involved in patient care ("frontline") and IPC professionals as proxy agents, that is, implementation support practitioners. While both types of implementation interventions aim to promote compliance with clinical interventions to prevent healthcare-associated infections (HAI), their tailoring may be vastly different, for example, due to different behavioural outcomes. Additionally, IPC teams, as recipients of empowering tailored interventions, are under-researched. To overcome this gap and improve conceptual clarity, we proposed a cascadic logic model for tailored IPC interventions (IPC-CASCADE). In the model, we distinguished between interventions by IPC professionals targeting clinicians and those targeting IPC professionals (first- and second-order implementation interventions, respectively). Tailoring implies selecting behaviour change techniques matched to prospectively-assessed determinants of either clinician compliance (in first-order interventions) or interventions by IPC professionals for frontline workers (in second-order interventions). This interventional cascade is embedded in the prevailing healthcare system. IPC-CASCADE is horizontally structured over time and vertically structured by hierarchy or leadership roles. IPC-CASCADE aims to highlight the potential of increasing the impact of tailored interventions by IPC professionals for clinicians (to improve their compliance) via tailored interventions for IPC professionals (to improve their work as proxy agents). It underlines the links that IPC professionals define between macro contexts (healthcare and hospitals) and frontline workers in HAI prevention. It is specific, i.e., "tailored" to IPC, and expected to assist implementation science to better conceptualise tailoring.

Effect of WeChat-Based Health Preaching Combined with an Enhanced Recovery after Surgery Model on Perioperative Limb Motor Function and Complications in Orthopaedic Patients

Objective

To evaluate the effect of WeChat-based health preaching combined with an enhanced recovery after surgery (ERAS) model on perioperative limb motor function and complications in orthopaedic patients.

Methods

By means of retrospective analysis, the medical data of 68 orthopaedic patients who received surgical treatment in our hospital (from 01, 2020–12, 2021) were collected, and the patients were equally divided into the study group (SG) and control group (CG) according to their admission order, with 34 cases each. From 7 d before surgery to the time of hospital discharge, WeChat-based health preaching combined with ERAS perioperative nursing was performed to patients in the SG, and routine orthopaedic perioperative nursing was performed to those in the CG. Before and after nursing, patients' Visual Analog Scale for Fatigue (VAS-F) scores, Houston Pain Outcome Instrument (HPOI) scores, and brief Fu-gI-Meyer (FMA) motor scores were investigated and the incidence rates of postoperative complications and nursing satisfaction of patients in the two groups were recorded.

Results

After nursing, SG obtained a significantly better VAS-F score and HPOI score (P < 0.001), significantly higher postoperative 7 d and predischarge lower limb FMA scores (20.06 ± 2.13 vs 18.38 ± 2.36, 27.50 ± 1.90 vs 24.09 ± 2.25, P < 0.05), and significantly lower annual incidence rate of complications compared with those of the CG (P < 0.05); and the nursing satisfaction scores of the SG and CG were 9.18 ± 0.82 points and 6.76 ± 0.91 points, respectively, indicating significantly higher nursing satisfaction in the SG than in the CG (P < 0.001).

Conclusion

The nursing model of WeChat-based health preaching combined with ERAS can effectively improve the knowledge level of orthopaedic patients, thereby improving their abilities of pain management and self-management, accelerating the recovery of their limb function, and reducing the incidence rate of postoperative complications. The patients are more satisfied with such nursing model, indicating its better promotion value.

Determinants of orthopedic physicians' self-reported compliance with surgical site infection prevention: results of the WACH-trial's pilot survey on COM-B factors in a German university hospital

BACKGROUND

Prevention of surgical site infections (SSIs), which due to their long-term consequences are especially critical in orthopedic surgery, entails compliance with over 20 individual measures. However, little is known about the psychosocial determinants of such compliance among orthopedic physicians, which impedes efforts to tailor implementation interventions to improve compliance. Thus, for this professional group, this pilot survey examined psychosocial determinants of self-reported compliance, which have been theoretically derived from the COM-B (Capability, Opportunity, Motivation and Behavior) model.

METHODS

In 2019, a cross-sectional survey was conducted in a tertiary care university orthopedic clinic in Hannover, Germany, as a pilot for the WACH-trial ("Wundinfektionen und Antibiotikaverbrauch in der Chirurgie" [Wound Infections and Antibiotics Consumption in Surgery]). Fifty-two physicians participated (38 surgeons, 14 anesthesiologists; response rate: 73.2%). The questionnaire assessed self-reported compliance with 26 SSI preventive measures, and its psychosocial determinants (COM-B). Statistical analyses included descriptive, correlational, and linear multiple regression modeling.

RESULTS

Self-reported compliance rates for individual measures varied from 53.8 to 100%, with overall compliance (defined for every participant as the mean of his or her self-reported rates for each individual measure) averaging at 88.9% (surgeons: 90%, anesthesiologists: 85.9%; p = 0.097). Of the components identified in factor analyses of the COM-B items, planning, i.e., self-formulated conditional plans to comply, was the least pronounced (mean = 4.3 on the 7-point Likert scale), while motivation was reported to be the strongest (mean = 6.3). Bi-variately, the overall compliance index co-varied with all four COM-B-components, i.e., capabilities (r = 0.512, p < 0.001), opportunities (r = 0.421, p = 0.002), planning (r = 0.378, p = 0.007), and motivation (r = 0.272, p = 0.051). After mutual adjustment and adjustment for type of physician and the number of measures respondents felt responsible for, the final backward regression model included capabilities (β = 0.35, p = 0.015) and planning (β = 0.29, p = 0.041) as COM-B-correlates.

CONCLUSION

Though based on a small sample of orthopedic physicians in a single hospital (albeit in conjunction with a high survey response rate), this study found initial evidence for positive correlations between capabilities and planning skills with self-reported SSI preventive compliance in German orthopedic physicians. Analyses of the WACH-trial will further address the role of these factors in promoting SSI preventive compliance in orthopedic surgery.

TRIAL REGISTRATION

This survey was conducted as part of the research project WACH ("Wundinfektionen und Antibiotikaverbrauch in der Chirurgie" [Wound Infections and Antibiotic Consumption in Surgery]), which has been registered in the German Clinical Trial Registry ( https://www.drks.de/ ; ID: DRKS00015502).

The Implementation of a Complication Avoidance Care Bundle Significantly Reduces Adverse Surgical Outcomes in Orthopedic Trauma Patients

Background: Surgical complications are associated with a significant burden to patients and hospitals and are increasingly discussed in recent literature. This cohort study reviewed surgery-related complications in a Level I trauma center. The effect of a complication avoidance care bundle on the rate of surgical complications was analyzed. Methods: All complications (surgical and nonsurgical) that occur in our trauma department are prospectively captured using a standardized documentation form and are discussed and analyzed in a weekly trauma Morbidity and Mortality (M&M) conference. Surgical complication rates are calculated using the annual surgical procedure numbers. Based on discussions in the M&M conference, a complication avoidance care bundle consisting of five measures was established: (1) Improving team situational awareness; (2) reducing operating room traffic by staff members and limiting door-opening events; (3) preoperative screening for infectious foci; (4) adapted preoperative antibiotic prophylaxis in anatomic regions with a high risk of infectious complications; and (5) use of iodine-impregnated adhesive drape. Results: The number of surgical procedures steadily increased over the study years, from 3587 in 2015 to 3962 in 2019 (an increase of 10.5%). Within this 5-year study period, the overall rate of surgical complications was 0.8%. Surgical site infections were the most frequently found complications (n = 40, 24.8% of all surgical complications), followed by screw malposition (n = 20, 12.4%), postoperative dislocations of arthroplasties (n = 18, 11.2%), and suboptimal fracture reduction (n = 18, 11.2%). Following implementation of the complication avoidance care bundle, the overall rate of surgical complications significantly decreased, from 1.14% in the year 2016 to 0.56% in the study year 2019, which represents a reduction of 51% within a 3-year time period. Conclusions: A multimodal strategy targeted at reducing the surgical complication rate can be successfully established based on a transparent discussion of adverse surgical outcomes. The combination of the different preventive measures was associated with reducing the overall complication rate by half within a 3-year time period.