Costs of an outbreak of wound infections in an orthopaedic ward

Ensuring appropriate timing of antimicrobial prophylaxis

BACKGROUND

Delivery of intravenous antibiotic prophylaxis within one hour prior to surgical incision is considered important in helping to decrease the incidence of surgical site infections, but methods to ensure compliance have not been established.

METHODS

All patients at our institution are subjected to a surgical "time-out" protocol to prevent wrong-site surgery. During a seven-week period, all patients undergoing spine surgery, total hip arthroplasty, or total knee arthroplasty had another safety initiative, that of ensuring that prophylactic intravenous antibiotics were administered at least one hour prior to incision, "piggybacked" onto our existing time-out verification checklist. In addition, we compared compliance during the study period with compliance during a three-month period prior to institution of this protocol and compliance for eighteen months after institution of this protocol.

RESULTS

The average time (and standard deviation) between the antibiotic administration and the incision was 26 +/- 12 minutes for all patients. The protocol was effective in ensuring antibiotic administration at the optimal time to 316 (99.1%) of the 319 patients. Analysis of a group of forty patients who had undergone total hip or knee replacement during the three months prior to the beginning of the study demonstrated a compliance rate of 65%. The difference between this baseline compliance rate and the rate during the study period was significant (p < 0.0001). The compliance rate was 97% for 160 patients who underwent similar procedures during the eighteen months after completion of the study. Independent audits demonstrated continuation of the significantly better compliance with timing of antibiotic prophylaxis for patients undergoing total hip and knee arthroplasty since the implementation of the protocol in our institution.

CONCLUSIONS

Piggybacking of verification of prophylactic antibiotic administration onto the wrong-site-surgery time-out protocol is an effective, cost-free, and easy-to-adopt method to ensure compliance with appropriate timing of prophylactic antibiotics.

Staphylococcus aureus, the major pathogen in orthopaedic and cardiac surgical site infections: a literature review

Due to the increasing number of orthopaedic and cardiac procedures, these units are considered as high-risk areas because of the potentially serious consequences of surgical site infections (SSI), primarily caused by Staphylococcus aureus. The goal of this review was to evaluate the impact of S. aureus on the incidence of SSI in these high risk wards. Studies were identified by a search on the MEDLINE literature using the following mesh terms: S. aureus, cardiac, orthopaedic, surgery, SSI. Beside, data from different surveillance systems were also included. Overall, biological investigation was performed only on a small proportion of identified SSIs. Of those identified, S. aureus represented the most common pathogen accounting for approximately 20% of all SSIs. Of the 59,274 hip prostheses reported from the HELICS surveillance network, S. aureus formed 48.6% of the pathogens (416 bacteria isolated). Similarly, it represented 43.7% of pathogens after coronary artery bypass grafting. Although S. aureus turned out to be the major pathogen, this work identifies the relative lack of knowledge on the overall incidence of S. aureus infections and on the impact of this pathogenic agent when taking into consideration the degree of wound contamination and category of SSI. There is a need for more detailed information on the role of S. aureus in the burden of surgical site infections and consequently how to establish multiple approach prevention programs.

Multiresistant Enterobacter cloacae outbreak in an intensive care unit associated with therapeutic beds

We report a multiresistant Enterobacter cloacae outbreak in an intensive care unit, associated with mattresses and with antibacterial-treated and vapour-permeable polyurethane synthetic mattress covers of therapeutic beds.

[Surgical wound infections due to Pseudomonas aeruginosa in orthopedic surgery]

OBJECTIVE

The department of infection control carried out an investigation to search for the origin of 4 surgical site infections and 1 wound colonization by Pseudomonas aeruginosa in patients having undergone orthopedic surgery.

PATIENTS AND METHODS

The authors retrospectively reviewed the medical records, the clinical data of the operating units, as well as the bacteriological assessments of the infected patients. Multiple environmental samples were made to screen for P. aeruginosa and care giving was evaluated.

RESULTS

The 5 patients underwent surgery between August and September 2001 with various surgeons and were followed-up by various paramedics. The surgical procedures were varied and performed in different operating rooms. Various P. aeruginosa serotypes were isolated. No specific event could be related to the infections concerning the surgical procedures. In 3 of the 5 patients, non-sterile cotton jersey had been used, either normally (plaster or plaster splint) or after sterilization (wrapping of wounded limbs before surgical procedure). The culture samplings of non-sterile jersey were always contaminated by Enterobacteriaceae or Pseudomonas sp., with 2 positives cultures of P. aeruginosa. Only one water sample was positive, whereas other environmental samples remained negative. The reorganization of jersey supply put an end to this epidemic phenomenon.

CONCLUSION

The most probable hypothesis for surgical wound infection was the cotton jersey in 3 of the 5 cases.

The efficacy of prophylactic intravenous antibiotics in elective foot and ankle surgery

A retrospective chart review of 555 patients who received elective foot and ankle surgeries between 1995 and 2001 at 1 outpatient podiatric hospital clinic was performed to evaluate the efficacy of preoperative intravenous antibiotic use. Only those patients who were having elective foot or ankle surgery for the first time, were being followed up at the hospital's outpatient clinic, and had a nontraumatic cause for their surgery were included in this study. A wound was considered infected when purulent material from the wound sites was noted and an organism(s) was cultured. A wound complication was defined as a superficial dehiscence, edema, erythema, or stitch abscess. Three hundred six (55.1%) patients received a preoperative antibiotic and 249 (44.9%) patients did not. Of the 306 patients who received a preoperative antibiotic, 9 (1.6%) acquired a postoperative wound infection, whereas 8 (1.4%) of the 249 patients who did not receive preoperative antibiotics acquired a postoperative infection. A logistic regression model and chi square tests of association were used to determine if preoperative antibiotic use, age, gender, type of surgical procedure, operative time, tourniquet use, past medical history, and internal fixation were predictive of or associated with postoperative wound infection or complication. None of the study factors was predictive of postoperative wound infection or complication (P >.01). Preoperative antibiotic use was associated with surgical category and internal fixation use (P <.001) but not postoperative wound infection or complication (P >.01). The results suggest that prophylactic intravenous antibiotic use in routine elective foot and ankle surgery is not warranted.

The economic costs of surgical site infection

BACKGROUND

Surgical site infections (SSIs) remain common and are a major cause of postoperative morbidity. Less well recognized is the cost of these complications, both in the direct costs of care and also in terms of lost economic productivity when workers are disabled as a result of an infection. This review was undertaken to bring into focus the relevant literature regarding the costs associated with SSI.

METHODS

Review of the pertinent English language literature.

RESULTS

The estimated costs of SSI vary as a function of locale, type of operation, and the extent (depth) of the infection itself. Superficial SSIs cared for in the National Health Service of the United Kingdom have an estimated cost of less that 400 dollars/case, whereas estimates range into the tens of thousands of dollars per case in the United States for complex infections such as infected joint prostheses or sternal infections following cardiac surgery. The magnitude of the problem is emphasized by a report from Denmark, which shows that the cost of care for surgical site infections consumes 0.5% of the annual hospital budget.

CONCLUSION

SSI is morbid and expensive. However, not all SSIs are the same. Reports of economic costs that do not stratify for the depth of the infection or the context in which the infection occurs are potentially misstating the magnitude of these complications.

Managing and maintaining a safe environment in the hospital setting

On entering hospital, patients and visitors assume that they are in a safe environment. Maintaining a safe environment in hospitals depends on not only the infrastructure, but also the equipment and materials that are used on the premises. Complaints about hospitals often include comments on the environment, its lack of cleanliness, poor food and the general look of debilitation. Key legislation for managing a safe environment is the Health and Safety at Work Act 1974. Complementary guidance includes the Control of Substances Hazardous to Health Regulations 1999 and the Environmental Protection Act 1990. The Incorporation of such legislation into local policies and guidelines ensures that healthcare staff can set standards to maintain the integrity of the patient's environment. This article will consider aspects of hospital life involved in maintaining a safe environment.

Monitoring infective complications following hip fracture

Hip fracture affects more than 55,000 people in the UK each year and this number is increasing. Because of their advanced age and other risk factors, hip fracture patients are at risk of developing infection and a variety of other non-infective complications. Surveillance of superficial wound and deep joint infection is important because of the large number of patients involved and represents a good example of targeted surveillance. Furthermore this may be conducted as part of a quality control programme monitoring other interventions such as prophylaxis for vascular thrombosis. However, to carry this out successfully, a simple but efficient system for recording, collecting and analysing data is required and adequate post-discharge surveillance must be carried out.

Financial burden of hospital-acquired Clostridium difficile infection

Clostridium difficile infection has become endemic in many hospitals and yet few data on the associated costs of such cases are available. We prospectively followed 50 consecutive cases of C. difficile infection and 92 control patients, who were admitted to the same geriatric wards within 72 h of the cases. Cases and controls had similar age, sex and major diagnosis distributions. Cases stayed significantly longer (mean 21.3 days, median 20.5 days; P < 0.001) in hospital than controls, including an average 14 days in a side room. Diarrhoea developed in cases on average 10.8 days after admission, which, when compared with a mean duration of stay for controls of 25.2 days, implies that C. difficile infection caused an increased duration of stay, as opposed to infection occurring because of longer residence. There was a significantly higher death rate in cases compared with controls (P < 0.01). Antibiotic treatment of C. difficile infection cost an average of Pounds 47 per case. The average number of laboratory investigations per day was similar for cases and controls, but the increased length of stay meant an extra cost for tests of approximately Pounds 210 per case. Assuming hotel costs of Pounds 150 (Pounds 200) per day stay (in a side room), 94% of the additional costs associated with C. difficile infection were due to increased duration of stay (Pounds 3850). The total identifiable increased cost of C. difficile infection was, therefore, in excess of Pounds 4000 per case. Such high costs can be used to justify expenditure on personnel and/or other control measures to reduce the incidence of this hospital-acquired infection.

Contamination risks from a high-speed bone burr

STUDY DESIGN

The authors recorded the contamination rate at a mock surgical site below a high-speed burr creating debris from a fresh-frozen allograft specimen.

OBJECTIVES

To document possible contamination rates associated with high-speed burr use.

SUMMARY OF BACKGROUND DATA

The literature contained no studies addressing a known rate of contamination from high-speed burr use.

METHODS

Samples of debris were collected in a mock-up of an operation involving bone burring. Set distances were maintained between objects within the field. High-speed bone burring was performed on fresh-frozen allograft bone specimens, and falling debris was collected on sterile culture plates. Control specimens were obtained randomly. Two hundred test and 20 control samples were collected by means of standard sterile techniques.

RESULTS

Thirty-five percent of the cultured specimens from the test group grew skin flora, compared with 10% from the control group (P = 0.02).

CONCLUSIONS

The authors propose that the higher contamination rate in the experimental samples resulted from airborne bone chips striking nonsterile surfaces before landing on the culture plates. Such contamination may increase the risk of wound infection.

An examination of nurses' practices when performing aseptic technique for wound dressings

The purpose of this study was to establish if nurses' actions when carrying out 'aseptic technique' using the 'gloves technique' are simple and based on up-to-date knowledge and do not incur unnecessary wastage. A sample of convenience was used involving 21 trained nurses. Observation and formal interviews were used to collect quantitative and qualitative data. Results showed that not all nurses in the sample applied a 'simple aseptic technique'. The rationale for the practice of aseptic technique was not always research based, though other aspects of wound management were derived from research findings. The study highlighted other areas of aseptic technique which require investigations.

Infection control in hospitals: has its quality-enhancing and cost-effective role been appreciated?

A review of data from surveys worldwide, including the United Kingdom and the United States, or morbidity and mortality and costs incurred as direct consequences of hospital-acquired infection is presented. These data testify to the role of hitherto somewhat undervalued Infection Control in hospitals as a key factor in the quality of medical care and also establish its contribution towards cost-effectiveness in various health care systems, including the National Health Service in the UK (NHS). It is appropriate, therefore, for Infection Control to be accorded proper appreciation and adequate funding. The achievement of these aims is likely to be helped by the recent changes in the NHS management system and supported by the requirements of Medical Audit and Hospital Accreditation Schemes.

How to cost and fund an infection control programme

Infection control (IC) services in the United Kingdom are provided as part of the microbiology services and therefore they have not, to date, been costed separately. This paper addresses the cost of providing the service, the savings that accrue from the IC policies in a hospital and, finally, the cost of infective episodes and outbreaks. The point of the exercise is to enable readers to cost their own services and separate the IC and microbiology budgets while maintaining the provision of service under one department.