Surgical site infections after hip arthroplasty in Norway, 2005-2011: influence of duration and intensity of postdischarge surveillance

The experience of infection prevention and control nurse (IPCN) in conducting post-discharge surveillance (PDS) of surgical site infections (SSI): A qualitative study

BACKGROUND

Surgical Site infections (SSI) are healthcare-associated infections (HAI) resulting from surgical procedures, which can increase morbidity, mortality, and economic burden. SSI surveillance is useful for detecting the magnitude of SSI cases and evaluating the impact of SSI prevention implementation. Post-discharge surveillance (PDS) of SSIs may identify more significant cases. To the best of our knowledge, there is no research exploring the experiences of Infection Prevention and Control Nurse (IPCN) in conducting PDS of SSI.

METHODS

To explore the experience of IPCN in conducting PDS of SSI. A qualitative transcendent phenomenological (descriptive) research, using a purposive sampling technique with 15 informants from 9 hospitals in Indonesia. Data were collected through in-depth direct and semi-structured interviews and analyzed using thematic analysis through Nvivo 12 plus software.

RESULTS

Five themes were generated, including the stages of PDS of SSI, the collaborative role of PDS of SSI officers, inhibiting factors of PDS of SSI, supporting factors of PDS of SSI, and optimization of PDS of SSI.

CONCLUSION

This study provides a deep understanding of the implementation PDS of SSI through an exploration of IPCN experiences, offering insights into the execution and various challenges faced by hospitals in conducting PDS of SSI.

Surgical site infection surveillance in German hospitals: a national survey to determine the status quo of digitalization

BACKGROUND

Surveillance of surgical site infections (SSI) relies on access to data from various sources. Insights into the practices of German hospitals conducting SSI surveillance and their information technology (IT) infrastructures are scarce. The aim of this study was to evaluate current SSI surveillance practices in German hospitals with a focus on employed IT infrastructures.

METHODS

German surgical departments actively participating in the national SSI surveillance module "OP-KISS" were invited in August 2020 to participate in a questionnaire-based online survey. Depending on whether departments entered all data manually or used an existing feature to import denominator data into the national surveillance database, departments were separated into different groups. Selected survey questions differed between groups.

RESULTS

Of 1,346 invited departments, 821 participated in the survey (response rate: 61%). Local IT deficits (n = 236), incompatibility of import specifications and hospital information system (n = 153) and lack of technical expertise (n = 145) were cited as the most frequent reasons for not using the denominator data import feature. Conversely, reduction of workload (n = 160) was named as the main motivation to import data. Questions on data availability and accessibility in the electronic hospital information system (HIS) and options to export data from the HIS for the purpose of surveillance, yielded diverse results. Departments utilizing the import feature tended to be from larger hospitals with a higher level of care.

CONCLUSIONS

The degree to which digital solutions were employed for SSI surveillance differed considerably between surgical departments in Germany. Improving availability and accessibility of information in HIS and meeting interoperability standards will be prerequisites for increasing the amount of data exported directly from HIS to national databases and laying the foundation for automated SSI surveillance on a broad scale.

Preoperative and postoperative risk factors for periprosthetic joint infection in primary total hip arthroplasty: A 1-year experience

BACKGROUND

Periprosthetic joint infection (PJI) in primary total hip replacement (THR) is one of the most important threats in orthopedic surgery, so one important surgeon’s target is to avoid or early diagnose a PJI. Although the incidence of PJI is very low (0.69%) in our department, with an average follow-up of 595 d, this infection poses a serious threat due to the difficulties of treatment and the lower functional outcomes after healing.

AIM

To study the incidence of PJI in all operations occurring in the year 2016 in our department to look for predictive signs of potential infection.

METHODS

We counted 583 THR for 578 patients and observed only 4 cases of infection (0.69%) with a mean follow-up of 596 d (min 30, max 1451). We reviewed all medical records to collect the data: duration and time of the surgery, presence, type and duration of the antibiotic therapy, preoperative diagnosis, blood values before and after surgery, transfusions, presence of preoperative drugs (in particularly anticoagulants and antiaggregant, corticosteroids and immunosuppressants), presence of some comorbidities (high body mass index, blood hypertension, chronic obstructive pulmonary disease, cardiac ischemia, diabetes, rheumatological conditions, previous local infections).

RESULTS

No preoperative, intraoperative, or postoperative analysis showed a higher incidence of PJI. We did not find any class with evident major odds of PJI. In our study, we did not find any border value to predict PJI and all patients had similar values in both groups (non-PJI and PJI). Only some categories, such as female patients, showed more frequency of PJI, but this difference related to sex was not statistically significant.

CONCLUSION

We did not find any category with a higher risk of PJI in THR, probably due to the lack of few cases of infection.

Limiting the Surveillance Period to 90 Days Misses a Large Portion of Infections in the First Year After Total Hip and Knee Arthroplasty

Background

In 2013, the Centers for Disease Control and Prevention reduced the periprosthetic joint infection (PJI) surveillance period from 1 year to 90 days for total hip (THA) and knee arthroplasty (TKA). Our aim was to determine how the reduced surveillance window impacts capture of PJIs.

Material and methods

Primary and revision THA and TKA cases were retrospectively identified in a statewide registry from October 1, 2015, to September 30, 2018. Infections were defined using the Periprosthetic Joint/Wound Infection measure (Centers for Medicare and Medicaid Services). We compared the cumulative incidence of infected primary and revision THA (pTHA/rTHA) and TKA (pTKA/rTKA) at 0-90 days and 91-365 days postoperatively.

Results

A total of 136,491 patients were included, 59.59% female, mean age 65.8 years, and mean body mass index 32.3 kg/m². The overall rate of PJI diagnosed by 1 year was 1.33%. The percent of infections diagnosed between 0-90 days and 91-365 days were pTHA 76.78% and 23.22%, rTHA 74.12% and 25.88%, pTKA 57.67% and 42.33%, and rTKA 53.78% and 46.22%, respectively. More infections were diagnosed after 90 days in pTKA than in pTHA and in rTKA than in rTHA (P < .0001). There was a higher risk of infection throughout the year when comparing rTKA to rTHA (P = .0374) but not when comparing pTKA to pTHA (P = .0518).

Conclusion

A substantial portion of infections are missed by the 90-day surveillance period. More infections are missed after TKA than after THA. Extension of the surveillance period would allow for identification of opportunities for quality improvement.

Surgical site infection in elective clean and clean-contaminated surgeries in developing countries

BACKGROUND

Surgical site infection (SSI) is both the most frequently studied healthcare-associated infection and the most common healthcare-associated infection in the developing world. A systematic review and meta-analysis was conducted to evaluate the relative size of this burden and to estimate the prevalence of SSI in clean and clean-contaminated surgeries in a large sample of countries in the developing world.

METHODS

A systematic search of the MEDLINE/PubMed, Scopus, and LILACS databases was conducted to identify studies providing the prevalence of SSI in elective clean and clean-contaminated surgeries in 39 countries or regions around the world. Data of interest were limited to publications from January 2000 to December 2017. Studies with information on the number of cases of SSI and number of total elective clean and clean-contaminated surgeries during the same period were included in this evaluation. Studies lacking clear definition of the total number of exposed patients were excluded.

RESULTS

Based on the combined data from the 99 articles evaluated in this analysis, the overall prevalence of SSI in elective clean and clean-contaminated surgeries was estimated to be 6% (95% confidence interval (CI) 5-7%). This increased to 15% (95% CI 6-27%) when considering only those reports with post-discharge surveillance data. The overall prevalence of SSI in Africa/Middle East, Latin America, Asia, and China was 10% (95% CI 6-15%), 7% (95% CI 5-10%), 4% (95% CI 4-5%), and 4% (95% CI 2-6%), respectively. Significant variability in the data was confirmed by both the funnel plot and the Egger test (p=0.008).

CONCLUSIONS

Although the data are variable, it is clear that the incidence of SSI in the developing world is higher than that in the developed world.

A positive association between nutritional risk and the incidence of surgical site infections: A hospital-based register study

Surgical site infections (SSI) are amongst the most common health care-associated infections and have adverse effects for patient health and for hospital resources. Although surgery guidelines recognize poor nutritional status to be a risk factor for SSI, they do not tell how to identify this condition. The screening tool Nutritional Risk Screening 2002 is commonly used at hospitals to identify patients at nutritional risk. We investigated the association between nutritional risk and the incidence of SSI among 1194 surgical patients at Haukeland University Hospital (Bergen, Norway). This current study combines data from two mandatory hospital-based registers: a) the incidence of SSI within 30 days after surgery, and b) the point-prevalence of patients at nutritional risk. Patients with more than 30 days between surgery and nutritional risk screening were excluded. Associations were assessed using logistic regression, and the adjusted odds ratio included age (continuous), gender (male/female), type of surgery (acute/elective) and score from The American Society of Anesthesiologists Physical Status Classification System. There was a significant higher incidence of SSI among patients at nutritional risk (11.8%), as compared to those who were not (7.0%) (p = 0.047). Moreover, the incidence of SSI was positively associated with the prevalence of nutritional risk in both simple (OR 1.76 (95% CI: 1.04, 2.98)) and adjusted (OR 1.81 (95% CI: 1.04, 3.16)) models. Answering “yes” to the screening questions regarding reduced dietary intake and weight loss was significantly associated with the incidence of SSI (respectively OR 2.66 (95% CI: 1.59, 4.45) and OR 2.15 (95% CI: 1.23, 3.76)). In conclusion, we demonstrate SSI to occur more often among patients at nutritional risk as compared to those who are not at nutritional risk. Future studies should investigate interventions to prevent both SSI and nutritional risk among surgical patients.

Rate and Risk Factors for Periprosthetic Joint Infection Among 36,494 Primary Total Hip Arthroplasties

BACKGROUND

As periprosthetic joint infections (PJIs) can have tremendous health and socioeconomic implications, recognizing patients at risk before surgery is of great importance. Therefore, we sought to determine the rate of and risk factors for deep PJI in patients undergoing primary total hip arthroplasty (THA).

METHODS

Clinical characteristics of patients treated with primary THA between January 1999 and December 2013 were retrospectively reviewed. These included patient demographics, comorbidities (including the Charlson/Deyo comorbidity index), length of stay, primary diagnosis, total/allogeneic transfusion rate, and in-hospital complications, which were grouped into local and systemic (minor and major). We determined the overall deep PJI rate, as well as the rates for early-onset (occurring within 2 years after index surgery) and late-onset PJI (occurring more than 2 years after surgery). A Cox proportional hazards regression model was constructed to identify risk factors for developing deep PJI. Significance level was set at 0.05.

RESULTS

A deep PJI developed in 154 of 36,494 primary THAs (0.4%) during the study period. Early onset PJI was found in 122 patients (0.3%), whereas late PJI occurred in 32 patients (0.1%). Obesity, coronary artery disease, and pulmonary hypertension were identified as independent risk factors for deep PJI after primary THA.

CONCLUSION

The rate of deep PJIs of the hip is relatively low, with the majority occurring within 2 years after THA. If the optimization of modifiable risk factors before THA can reduce the rate of this complication remains unknown, but should be attempted as part of good practice.

Interhospital Comparison of Surgical Site Infection Rates in Orthopedic Surgery

OBJECTIVE To investigate whether comparison by deep or adjusted deep surgical site infection (SSI) rates in orthopedic surgeries are a better basis for feedback to Finnish hospitals than overall SSI rates DESIGN Retrospective cohort study SETTING Hospitals conducting surveillance of hip arthroplasties (HPROs) and knee arthroplasties (KPROs) in the Finnish Hospital Infection Program METHODS We analyzed surveillance data for 73,227 HPROs and 56,860 KPROs performed in 18 hospitals during 1999-2014. For each hospital, the overall, deep, and adjusted deep SSI rates with 95% confidence intervals (CIs) were calculated, and the hospital ranks were simulated in the Bayesian framework. Adjustments were performed using relevant patient and hospital characteristics. The correlation between the median expected hospital ranks in overall versus deep SSI rates and deep vs adjusted deep SSI rates were assessed using Spearman's correlation coefficient ρ. RESULTS For HPRO, the overall SSI rates ranged from 0.92 to 6.83, the deep SSI rates ranged from 0.34 to 1.86, and the adjusted deep hospital-specific SSI rates ranged from 0.37 to 1.85. For KPRO, the overall SSI rates ranged from 0.71 to 5.03, the deep SSI rates ranged from 0.42 to 1.60, and the adjusted deep hospital-specific SSI rates ranged from 0.56 to 1.55. For both procedures, the 95% CIs of the rates between hospitals largely overlapped; only single outliers were detected. Hospital rank did not correlate between overall and deep SSI rates (HPRO, ρ=0.03; KPRO, ρ=0.40), but a correlation was observed in hospital rank for deep and adjusted deep SSI rates (HPRO, ρ=0.85; KPRO, ρ=0.94). CONCLUSION Deep SSI rates may be a better tool for interhospital comparisons than overall SSI rates. Although the adjustment could lead to fairer hospital ranking, it is not always necessary for feedback. Infect Control Hosp Epidemiol 2017;38:423-429.

Epidemiology of patients with MSSA versus MRSA infections of orthopedic implants: Retrospective study of 115 patients

Factors that predict the occurrence of a surgical site infection due to methicillin-resistant Staphylococcus aureus (MRSA) are not well known; however this information could be used to modify the recommended antimicrobial prophylaxis. We carried out a retrospective study of S. aureus infections on orthopedic implants to determine: (1) whether epidemiological factors can be identified that predict a MRSA infection, (2) the impact of these factors as evidenced by the odds ratio (OR).

HYPOTHESIS

Risk factors for a MRSA infection can be identified from a cohort of patients with S. aureus infections.

MATERIALS AND METHODS

We identified 244 patients who experienced a S. aureus surgical site infection (SSI) in 2011-2012 documented by intraoperative sample collection. Of these 244 patients, those who had a previous SSI (n=44), those with a SSI but no orthopedic implant (n=80) or those who had the infection more than 1-year after the initial surgery (n=5) were excluded. This resulted in 115 patients (53 arthroplasty, 62 bone fixation) being analyzed for this study. There were 24 MRSA infections and 91 MSSA infections. The following factors were evaluated in bivariate and multifactorial analysis: age, sex, type of device (prosthesis/bone fixation), predisposition (diabetes, obesity, kidney failure), and environmental factors (hospitalization in intensive care unit within past 5 years, nursing home stay).

RESULTS

Two factors were correlated with the occurrence of MRSA infections. (1) Nursing home patients had a higher rate of MRSA infections (67% vs. 18%, P=0.017) with an OR of 8.42 (95% CI: 1.06-66.43). (2) Patients who had undergone bone fixation had a lower rate of MRSA infections than patients who had undergone arthroplasty (13% vs. 30%, P=0.023), OR 0.11 (95% CI: 0.02-0.56). Although the sample size was too small to be statistically significant, all of the patients with kidney failure (n=4) had a MRSA infection.

DISCUSSION

Since these MRSA infection risk factors are easy to identify, the antimicrobial prophylaxis could be adapted in these specific patient groups.

Reducing 30-day Readmission After Joint Replacement

Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve.

The quality of denominator data in surgical site infection surveillance versus administrative data in Norway 2005-2010

Background

High quality of surveillance systems for surgical site infections (SSIs) is the key to their usefulness. The Norwegian Surveillance System for Antibiotic Consumption and Healthcare-Associated Infections (NOIS) was introduced by regulation in 2005, and is based largely on automated extraction of data from underlying systems in the hospitals.

Methods

This study investigates the quality of NOIS-SSI’s denominator data by evaluating completeness, representativeness and accuracy compared with de-identified administrative data for 2005–2010. Comparisons were made by region, hospital type and size, age and sex for 4 surgical procedures.

Results

The completeness of NOIS improved from 29.2 % in 2005 to 79.8 % in 2010. NOIS-SSI became representative over time for most procedures by hospital size and type, but not by region. It was representative by age and sex for all years and procedures. Accuracy was good for all years and procedures by all explanatory variables.

Conclusions

A flexible and incremental implementation strategy has encouraged the development of computer-based surveillance systems in the hospitals which gives good accuracy, but the same strategy has adversely affected the completeness and representativeness of the denominator data. For the purpose of evaluating risk factors and implementing prevention and precautionary measures in the individual hospitals, representativeness seems sufficient, but for benchmarking and/or public reporting it is not good enough.