Mortality rate, length of stay and extra cost of sternal surgical site infections following coronary artery bypass grafting in a private medical centre in Turkey

Clinical and economic burden of surgical complications during hospitalization for digestive cancer surgery in France

BACKGROUND

Surgical complications and particularly infections after digestive cancer surgery remain a major health and economic problem and its burden in France is not well documented.

AIMS

The aim of this study was to analyse recent data regarding surgical complications in patients undergoing major digestive cancer surgery, and to estimate its burden for the French society.

METHODS AND RESULTS

Using the 2018 French hospital discharge database and 2017 National CostStudy we studied hospital stays for surgical resection in patients withdigestive cancer. The population was divided into three groups based onpostoperative outcomes: no complications (NC), related infectious complications (RIC) and other complications. The main analysis compared the length and cost per stay between RIC and NC. Forty-Four thousand one hundred and twenty-three stays following a digestive cancer resection were identified. Lower gastro-intestinal cancers were the most prevalent representing 74.8% of stays, the rate of malnutrition was 32.8% and 15.8% of patients presented RIC. Mean (SD) length of stay varied from 11,7 (9.0) days for NC to 25,5 days (19.5) for RIC (p < 0.01). The mean cost per patients' stay (SD) varied from €10 641 (€ 5897) for the NC to €18 720 (€7905) for RIC (p < .01).

CONCLUSION

The risk of RIC after digestive cancer resection remains high (>15%) and was associated with significantly longer length of stay and higher cost per stay. Although important prevention plans have been implemented in recent years, care strategies are still needed to alleviate the burden on patients and the healthcare system.

Negative-Pressure Wound Therapy for Prevention of Sternal Wound Infection after Adult Cardiac Surgery: Systematic Review and Meta-Analysis

The results of current studies are not conclusive on the efficacy of incisional negative-pressure wound therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery. A systematic review of the literature was performed through PubMed, Scopus and Google to identify studies which investigated the efficacy of NPWT to prevent SWI after adult cardiac surgery. Available data were pooled using RevMan and Meta-analyst with random effect models. Out of 191 studies retrieved from the literature, ten fulfilled the inclusion criteria and were included in this analysis. The quality of these studies was judged fair for three of them and poor for seven studies. Only one study was powered to address the efficacy of NPWT for the prevention of postoperative SWI. Pooled analysis of these studies showed that NPWT was associated with lower risk of any SWI (4.5% vs. 9.0%, RR 0.54, 95% CI 0.34–0.84, I2 48%), superficial SWI (3.8% vs. 4.4%, RR 0.63, 95% CI 0.29–1.36, I2 65%), and deep SWI (1.8% vs. 4.7%, RR 0.46, 95% CI 0.26–0.74, I2 0%), but such a difference was not statistically significant for superficial SWI. When only randomized and alternating allocated studies were included, NPWT was associated with a significantly lower risk of any SWI (3.3% vs. 16.5%, RR 0.22, 95% CI 0.08–0.62, I2 0%), superficial SWI (2.6% vs. 12.4%, RR 0.21, 95% CI 0.06–0.69, I2 0%), and deep SWI (1.2% vs. 4.8%, RR 0.17, 95% CI 0.03–0.95, I2 0%). This pooled analysis showed that NPWT may prevent postoperative SWI after adult cardiac surgery. NPWT is expected to be particularly useful in patients at risk for surgical site infection and may significantly reduce the burden of resources needed to treat such a complication. However, the methodology of the available studies was judged as poor for most of them. Further studies are needed to obtain conclusive results on the potential benefits of this preventative strategy.

Cost-effectiveness analysis of an active 30-day surgical site infection surveillance at a tertiary hospital in Ghana: evidence from HAI-Ghana study

OBJECTIVE

To assess the cost-effectiveness of an active 30-day surgical site infection (SSI) surveillance mechanism at a referral teaching hospital in Ghana using data from healthcare-associated infection Ghana (HAI-Ghana) study.

DESIGN

Before and during intervention study using economic evaluation model to assess the cost-effectiveness of an active 30-day SSI surveillance at a teaching hospital. The intervention involves daily inspection of surgical wound area for 30-day postsurgery with quarterly feedback provided to surgeons. Discharged patients were followed up by phone call on postoperative days 3, 15 and 30 using a recommended surgical wound healing postdischarge questionnaire.

SETTING

Korle-Bu Teaching Hospital (KBTH), Ghana.

PARTICIPANTS

All prospective patients who underwent surgical procedures at the general surgical unit of the KBTH.

MAIN OUTCOME MEASURES

The primary outcome measures were the avoidable SSI morbidity risk and the associated costs from patient and provider perspectives. We also reported three indicators of SSI severity, that is, length of hospital stay (LOS), number of outpatient visits and laboratory tests. The analysis was performed in STATA V.14 and Microsoft Excel.

RESULTS

Before-intervention SSI risk was 13.9% (62/446) as opposed to during-intervention 8.4% (49/582), equivalent to a risk difference of 5.5% (95% CI 5.3 to 5.9). SSI mortality risk decreased by 33.3% during the intervention while SSI-attributable LOS decreased by 32.6%. Furthermore, the mean SSI-attributable patient direct and indirect medical cost declined by 12.1% during intervention while the hospital costs reduced by 19.1%. The intervention led to an estimated incremental cost-effectiveness ratio of US$4196 savings per SSI episode avoided. At a national scale, this could be equivalent to a US$60 162 248 cost advantage annually.

CONCLUSION

The intervention is a simple, cost-effective, sustainable and adaptable strategy that may interest policymakers and health institutions interested in reducing SSI.

Factors Associated With High Resource Use in Elective Adult Cardiac Surgery From 2005 to 2016

BACKGROUND

Lack of consensus remains about factors that may be associated with high resource use (HRU) in adult cardiac surgical patients. This study aimed to identify patient-related, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations.

METHODS

Data from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft, valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU.

RESULTS

An estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34,700 (interquartile range, $26,800- to $47,100), with the HRU (N = 175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient-related characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-White race, and highest income quartile. Hospital factors associated with HRU were low-volume hospitals for both coronary artery bypass graft and valvular operations. Among postoperative outcomes, mortality, infectious complications, extracorporeal membrane oxygenation use, and hospitalization for more than 8 days were associated with greater odds of HRU.

CONCLUSIONS

In this nationwide study of elective cardiac surgical patients, several important patient-related and hospital factors, including patients' race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning.

Prediction and Analysis of Length of Stay Based on Nonlinear Weighted XGBoost Algorithm in Hospital

An improved nonlinear weighted extreme gradient boosting (XGBoost) technique is developed to forecast length of stay for patients with imbalance data. The algorithm first chooses an effective technique for fitting the duration of stay and determining the distribution law and then optimizes the negative log likelihood loss function using a heuristic nonlinear weighting method based on sample percentage. Theoretical and practical results reveal that, when compared to existing algorithms, the XGBoost method based on nonlinear weighting may achieve higher classification accuracy and better prediction performance, which is beneficial in treating more patients with fewer hospital beds.

Effects of Plasma-Lyte® and 0.9% saline in renal function after deceased-donor kidney transplant: a randomized controlled trial

BACKGROUND

The influence of different crystalloid solutions infused during deceased-donor kidney transplant on the incidence of delayed graft function remains unclear. We investigated the influence of Plasma-Lyte® vs. 0.9% saline on the incidence of delayed graft function in deceased-donor kidney transplant recipients.

METHODS

We conducted a single-blind randomized controlled trial of 104 patients aged 18 to 65 years who underwent deceased-donor kidney transplant under general anesthesia. Patients were randomly assigned to receive either Plasma-Lyte® (n = 52) or 0.9% saline (n = 52), at the same infusion volume, for intraoperative fluid replacement. The primary outcome was the occurrence of delayed graft function. Secondary outcomes included metabolic and electrolytic changes at the end of surgery.

RESULTS

Two patients in the Plasma-Lyte® group and one in the 0.9% saline group died postoperatively and were not included for analysis. The incidence of delayed graft function in Plasma-Lyte® and 0.9% saline groups were 60.0% (95% Confidence Interval [95% CI 46.2-72.4]) and 74.5% (95% CI 61.1-84.4), respectively (p = 0.140). Mean (standard deviation) values of immediate postoperative pH and serum chloride levels in Plasma-Lyte® and 0.9% saline groups were 7.306 (0.071) and 7.273 (0.061) (p = 0.013), and 99.6 (4.2) mEq.L^-1 and 103.3 (5.6) mEq.L^-1, respectively (p < 0.001). All other postoperative metabolic and electrolyte variables were not statistically different at the immediate postoperative period (p > 0.05).

CONCLUSION

In deceased-donor kidney transplant recipients, the incidence of delayed graft function is not influenced by Plasma-Lyte® or 0.9% saline used for intraoperative fluid replacement.

The Economic Implications of Introducing Single-Patient ECG Systems for Cardiac Surgery in Australia

Introduction

Sternal wound infections (SWIs) are severe adverse events of cardiac surgery. This study aimed to estimate the economic burden of SWIs following coronary artery bypass grafts (CABG) in Australia. It also aimed to estimate the national and hospital cost-benefit of adopting single-patient electrocardiograph (spECG) systems for CABG monitoring, a measure that reduces the rate of surgical site infections (SSIs).

Material and Methods

A literature review, which focused on CABG-related SSIs, was conducted to identify data which were then used to adapt a published Markov cost-effectiveness model. The model adopted an Australian hospital perspective.

Results

The average SWI-related cost of care increase per patient was estimated at 1022 Australian dollars (AUD), and the annual burden to the Australian health care system at AUD 9.2 million. SWI burden comprised 360 additional intensive care unit (ICU) days; 1979 additional general ward (GW) days; and 186 readmissions. Implementing spECG resulted in 103 fewer ICU days, 565 fewer GW days, 48 avoided readmissions, and a total national cost saving of AUD 2.5 million, annually. A hospital performing 200 yearly CABGs was estimated to save AUD 54,830.

Conclusion

SWIs cause substantial costs to the Australian health care system. Implementing new technologies shown to reduce the SWI rate is likely to benefit patients and reduce costs.

Economic burden of surgical site infections in patients undergoing cardiac surgery†

OBJECTIVES

This study aimed to determine the additional costs and length of stay (LOS) due to surgical site infections (SSIs) after coronary artery bypass grafting (CABG) at Jena University Hospital.

METHODS

The data of 999 consecutive patients who underwent CABG from January 2013 to December 2014 were collected. We extracted the number, type and duration of antimicrobial therapy and V.A.C.® therapy (negative pressure wound therapy) treatments and calculated the additional SSI-related costs based on the hospital's perspective. We also evaluated the prolongation of LOS using a multistate model and calculated the costs due to the additional LOS.

RESULTS

In total, 983 patients were included in our analysis, and 126 patients with SSIs following CABG were identified during the study period; 124 patients with SSIs (98.4%) were discharged alive. The mean cost of antimicrobial therapy to treat the SSIs was €818 [95% confidence interval (CI) 392-1245], and the mean cost of V.A.C. therapy was €1179 (95% CI 748-1610) per infected patient. The mean additional LOS due to SSIs (±standard error) was estimated to be 9.3 ± 2.6 days. The cost per SSI-infected patient attributable to the additional LOS was €9444 (95% CI 4242-14 645).

CONCLUSIONS

SSIs following CABG are associated with an additional LOS and a significant economic burden depending on the classification of SSI. A very important component of the additional cost is the prolongation of LOS. Therefore, it is essential to shorten the hospital stay due to SSIs as far as possible.

Surgical site infection and costs in low- and middle-income countries: A systematic review of the economic burden

BACKGROUND

Surgical site infection (SSI) is a worldwide problem which has morbidity, mortality and financial consequences. The incidence rate of SSI is high in Low- and Middle-Income countries (LMICs) compared to high income countries, and the costly surgical complication can raise the potential risk of financial catastrophe.

OBJECTIVE

The aim of the study is to critically appraise studies on the cost of SSI in a range of LMIC studies and compare these estimates with a reference standard of high income European studies who have explored similar SSI costs.

METHODS

A systematic review was undertaken using searches of two electronic databases, EMBASE and MEDLINE In-Process & Other Non-Indexed Citations, up to February 2019. Study characteristics, comparator group, methods and results were extracted by using a standard template.

RESULTS

Studies from 15 LMIC and 16 European countries were identified and reviewed in full. The additional cost of SSI range (presented in 2017 international dollars) was similar in the LMIC ($174-$29,610) and European countries ($21-$34,000). Huge study design heterogeneity was encountered across the two settings.

DISCUSSION

SSIs were revealed to have a significant cost burden in both LMICs and High Income Countries in Europe. The magnitude of the costs depends on the SSI definition used, severity of SSI, patient population, choice of comparator, hospital setting, and cost items included. Differences in study design affected the comparability across studies. There is need for multicentre studies with standardized data collection methods to capture relevant costs and consequences of the infection across income settings.

Attributable cost and extra length of stay of surgical site infection at a Ghanaian teaching hospital

BACKGROUND

Limited information is available on the financial impact of healthcare associated infections in Sub-Saharan Africa. A prospective case-control study was undertaken at Korle-Bu Teaching Hospital, Ghana, to calculate the cost of surgical site infections (SSI).

METHODS

We studied 446 adults undergoing surgery from the surgical department. In all, 40 patients with SSI and 40 control patients without SSI were matched by type of surgery, wound class, ASA, sex and age. The direct and indirect costs to patients were obtained from patients and their carers, daily. The cost of drugs was confirmed with the pharmacy at the department.

RESULTS

The prevalence rate for SSI was 11% of the total 446 cases sampled between June and August 2017. On average patients with SSI who undertook hernia surgery paid approximately US$ 392 more than the matched controls without SSI. The least difference was recorded amongst patients who had thyroid surgery, a difference of US$ 42. The results show that for all surgical procedures, SSI patients report excess length of stay. The additional days range from 1 day for limb amputation, to 16 days for rectal surgery.

CONCLUSIONS

In this study, patients with SSI experienced significant prolongation of hospitalisation and increased use of health care costs. In many cases, the indirect costs were much higher than direct costs. These findings support the need to implement preventative interventions for patients hospitalised for various surgical procedures at the Korle Bu Teaching Hospital.

Do antibacterial skin sutures reduce surgical site infections after elective open abdominal surgery? - Study protocol of a prospective, randomized controlled single center trial

BACKGROUND

Surgical site infections (SSI) remain one of the most common complications in conventional abdominal surgery with an incidence between 4% and 19% (Sandini et al., Medicine (Baltimore) 95:e4057, 2016) in the literature. It is unclear whether the use of coated suture material for skin closure reduces the risk of SSI. In line with in-vitro results, we hypothesize that the use of antibacterial skin sutures (triclosan-coated poliglecaprone 25) reduces the rate of SSI after open abdominal surgery.

METHODS/DESIGN

To prevent SSI, triclosan-coated poliglecaprone 25 sutures will be tested against un-coated suture material for skin closure after elective open abdominal surgery of 364 patients. The study is planned as a single-center, prospective randomized controlled trial. Patients will be followed for 30 days after surgery to detect and document wound complications. The rate of SSI after 30 days will be analyzed in both groups.

DISCUSSION

If we can confirm the proposed hypothesis in our study, this could be a promising and feasible approach to lower SSI after open abdominal surgery. By lowering the rate of SSI this might offer a cost-saving and morbidity-reducing procedure.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00010047 . Registered on 05.01.2017.

Associations of Hospital Length of Stay with Surgical Site Infections

BACKGROUND

Surgical site infections (SSI) are a major cause of morbidity and mortality in surgical patients. Postoperative and total hospital length of stay (LOS) are known to be prolonged by the occurrence of SSI. Preoperative LOS may increase the risk of SSI. This study aims at identifying the associations of pre- and postoperative LOS in hospital and intensive care with the occurrence of SSI.

METHODS

This observational cohort study includes general, orthopedic trauma and vascular surgery patients at two tertiary referral centers in Switzerland between February 2013 and August 2015. The outcome of interest was the 30-day SSI rate.

RESULTS

We included 4596 patients, 234 of whom (5.1%) experienced SSI. Being admitted at least 1 day before surgery compared to same-day surgery was associated with a significant increase in the odds of SSI in univariate analysis (OR 1.65, 95% CI 1.25-2.21, p < 0.001). More than 1 day compared to 1 day of preoperative hospital stay did not further increase the odds of SSI (OR 1.08, 95% CI 0.77-1.50, p = 0.658). Preoperative admission to an intensive care unit (ICU) increased the odds of SSI as compared to hospital admission outside of an ICU (OR 2.19, 95% CI 0.89-4.59, p = 0.057). Adjusting for potential confounders in multivariable analysis weakened the effects of both preoperative admission to hospital (OR 1.38, 95% CI 0.99-1.93, p = 0.061) and to the ICU (OR 1.89, 95% CI 0.73-4.24, p = 0.149).

CONCLUSION

There was no significant independent association between preoperative length of stay and risk of SSI while SSI and postoperative LOS were significantly associated.

Estimating excess length of stay due to healthcare-associated infections: a systematic review and meta-analysis of statistical methodology

BACKGROUND

Healthcare-associated infection (HCAI) affects millions of patients worldwide. HCAI is associated with increased healthcare costs, owing primarily to increased hospital length of stay (LOS) but calculating these costs is complicated due to time-dependent bias. Accurate estimation of excess LOS due to HCAI is essential to ensure that we invest in cost-effective infection prevention and control (IPC) measures.

AIM

To identify and review the main statistical methods that have been employed to estimate differential LOS between patients with, and without, HCAI; to highlight and discuss potential biases of all statistical approaches.

METHODS

A systematic review from 1997 to April 2017 was conducted in PubMed, CINAHL, ProQuest and EconLit databases. Studies were quality-assessed using an adapted Newcastle-Ottawa Scale (NOS). Methods were categorized as time-fixed or time-varying, with the former exhibiting time-dependent bias. Two examples of meta-analysis were used to illustrate how estimates of excess LOS differ between different studies.

FINDINGS

Ninety-two studies with estimates on excess LOS were identified. The majority of articles employed time-fixed methods (75%). Studies using time-varying methods are of higher quality according to NOS. Studies using time-fixed methods overestimate additional LOS attributable to HCAI. Undertaking meta-analysis is challenging due to a variety of study designs and reporting styles. Study differences are further magnified by heterogeneous populations, case definitions, causative organisms, and susceptibilities.

CONCLUSION

Methodologies have evolved over the last 20 years but there is still a significant body of evidence reliant upon time-fixed methods. Robust estimates are required to inform investment in cost-effective IPC interventions.

Relationship between endotoxin core, staphylococcal and varicella antibody levels and outcome following aortic valve replacement surgery: a prospective observational study

Background

Morbidity and mortality following cardiac valve surgery is high. Immunity is an important contributor to outcome. This study examines the relationship of staphylococcal and endotoxin antibody levels to outcome following cardiac surgery.

Methods

Using enzyme-linked immunosorbent assays (ELISA), we measured pre-operative levels of antibodies to endotoxin core (EndoCAb); 3 common staphylococcal epitopes and varicella on saved serum of 60 adult patients scheduled to undergo elective primary surgical aortic valve replacement (AVR). Primary outcome measure was post-operative length of stay (LOS) in hospital with secondary outcomes being development of infective complications, length of stay on the intensive care unit (ICU) and 30-day mortality. Patients were quartiled according to antibody levels and outcomes compared between the quartile groups using Mann-Whitney tests for length of stay and Fisher's test for development of infection.

Results

Sixty patients (34 M, 26 F) were recruited with mean age 73 years (IQR 66-78), mean body mass index (BMI) 27.7 (IQR 25-31) and EuroSCORE II 1.44 (0.95-1.99). Those patients in the lower quartile for pre-operative antibody level had a longer post-operative stay than the upper quartile. EndoCAb (median IgG level Q1 42.2 MU/ml vs Q4 256 MU/ml) 9 vs 6 days, p = 0.025; alpha-toxin (median IgG level Q1 63 U vs Q4 558 U) 10 vs 7 days, p = 0.034; teichoic acid (median IgG level Q1 14 U vs Q4 419 U) 10 vs 8 days, p = 0.441; staphylococcal enterotoxin A (median IgG level Q1 55 U vs Q4 427 U) 9 vs 7 days, p = 0.865; varicella zoster (median IgG level Q1 1.325 U vs Q4 2.54 U) 8 vs 7 days, p = 1.0; and combined antibody levels 10 vs 6 days, p = 0.017. There were no differences in the number developing post-operative infections for each antibody type. The combined antibody analysis suggested a reduction in proportion of individuals developing infection from the upper vs lower quartile: 0 vs 0.33, p = 0.042.

Conclusions

This study again suggests the inverse relationship between endotoxin core antibody levels and outcome following aortic valve surgery as well as suggesting a similar relationship with antibodies to staphylococcus. There is no such relationship for antibody levels against an organism not providing a peri-operative threat. Understanding this relationship may enable therapeutic manipulation of immune status, re-evaluation of risk and further investigation of the low immune state.

Trial registration

The patients in this study are a sub-group of the RELIEF AS study.ClinicalTrials.gov identifier NCT02174471.

The association of surgical drains with surgical site infections - A prospective observational study

BACKGROUND

Surgical drains are widely used despite limited evidence in their favor. This study describes the associations between drains and surgical site infections (SSI).

METHODS

This prospective observational double center study was performed in Switzerland between February 2013 and August 2015.

RESULTS

The odds of SSI in the presence of drains were increased in general (OR 2.41, 95%CI 1.32-4.30, p = 0.004), but less in vascular and not in orthopedic trauma surgery. In addition to the surgical division, the association between drains and SSI depended significantly on the duration of surgery (p = 0.01) and wound class (p = 0.034). Furthermore, the duration of drainage (OR 1.24, 95%CI 1.15-1.35, p < 0.001), the number (OR 1.74, 95%CI 1.09-2.74, p = 0.019) and type of drains (open versus closed: OR 3.68, 95%CI 1.88, 6.89, p < 0.001) as well as their location (overall p = 0.002) were significantly associated with SSI.

CONCLUSIONS

The general use of drains is discouraged. However, drains may be beneficial in specific surgical procedures.

Prevalence of depression and its associated factors in patients post-coronary artery bypass graft surgery

This research aimed to determine the depression level and its correlation experienced by post-coronary artery bypass graft patients after being discharged from cardiac intensive care units. A cross-sectional design was employed for assessing variables. The Self-rating Depression Scale, as proposed by Zung, was used by the researchers on a convenience sample of Jordanian patients (N = 143) who were approached soon after their discharge from the targeted units. The results suggested that the level of depression among Jordanian patients was relatively high (M = 62.7, SD = 5.6). Moreover, depression was significantly higher among female, unmarried and unemployed patients. Patients who received their information about coronary artery bypass graft surgery from nurses had a lower level of depression. Age, length of stay in the cardiac intensive care unit and hospital type significantly predicted the level of depression. The research concluded that the post-coronary artery bypass graft patients who experienced an early onset depression required more attention to highlight the importance of supportive interventions.

Effects of nurse-led clinical pathway in coronary artery bypass graft surgery: A quasi-experimental study

AIMS AND OBJECTIVES

To develop and evaluate the effects of a nurse-led clinical pathway for patients undergoing coronary artery bypass graft surgery.

BACKGROUND

A clinical pathway is a multidisciplinary care plan, based on evidence and guidelines to provide consistent, quality care to patients and improve outcomes.

DESIGN

Prospective, quasi-experimental design.

METHODS

Patients hospitalised for coronary artery bypass graft between April 2014-November 2015 in a hospital in Turkey were studied. First 42 usual care patients were enrolled to determine outcomes and plan for the development of the clinical pathway followed by 40 patients in the newly developed clinical pathway. The primary outcome was length of stay and secondary outcomes related to recovery from surgery (e.g., time to extubation, first feeding).

RESULTS

The mean age for the clinical pathway group was 60 and for usual care was 63 years. Most were male (CP = 78%, UC = 69%). There were significant differences between groups for the primary outcome. Length of stay in the intensive care unit was 38.9 hr for CP and 50.7 hr for usual care patients p < .01. Total hospital time was 144.4 hr for clinical pathway and 162.2 hr for usual care, p < .05. For secondary measures, the following times were less for the clinical pathway group than for the usual care: time to extubation and nasogastric tube removal (5.7 vs. 8.6 hr, p < .01), first oral feeding (4.7 vs. 10.9 hr, p < .001), first mobilisation (8.4 vs. 22.9 hr, p < .001) and first bowel movement (69.8 vs. 85.9 hr, p < .01). There were no statistically significant differences in the 3-month readmission rates and complication rates between the groups, except the renal complication rates were higher in the usual care (n = 16, 38%) than in the clinical pathway (n = 7, 17.5%) (p < .05).

CONCLUSION

The nurse-led clinical pathway was effective in improving length of stay in both the ICU and hospital as well as the secondary outcomes.

RELEVANCE TO CLINICAL PRACTICE

This study contributes to previous studies supporting clinical pathway use can improve the length of stay and quality of care in patients undergoing coronary artery bypass graft surgery.

The role of preoperative blood parameters to predict the risk of surgical site infection

BACKGROUND

Routine preoperative blood work is not recommended but selected biochemical markers may predict the risk of surgical site infection (SSI). This study examines the association between preoperative biochemical markers and the risk of SSI.

METHODS

This observational cohort study, nested in a randomized controlled trial, was conducted at two tertiary referral centers in Switzerland.

RESULTS

122 (5.8%) of 2093 patients experienced SSI. Preoperative increasing levels of albumin (OR 0.93), CRP (OR 1.34), hemoglobin (OR 0.87) and eGFR (OR 0.90) were significantly associated with the odds of SSI. The same accounts for categorized parameters. The highest area under the curve from ROC curves was 0.62 for albumin. Positive predictive values ranged from 6.4% to 9.5% and negative predictive values from 94.8% to 95.7%. The association of CRP, mildly and moderately decreased eGFR and hemoglobin with the odds of SSI remained significant on multivariate analysis.

CONCLUSIONS

Our results do not support generally delaying elective surgery based on preoperative blood results. However, it may be considered in situations with potentially severe sequelae of SSI.

Building a Successful Infection Prevention Program: Key Components, Processes, and Economics

Infection control is the discipline responsible for preventing health care-associated infections (HAIs) and has grown from an anonymous field, to a highly visible, multidisciplinary field of incredible importance. There has been increasing focus on prevention rather than control of HAIs. Infection prevention programs (IPPs) have enormous scope that spans multiple disciplines. Infection control and the prevention and elimination of HAIs can no longer be compartmentalized. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program.

Nosocomial infections among acute leukemia patients in China: An economic burden analysis

BACKGROUND

The economic burden associated nosocomial infections (NIs) in patients with acute leukemia (AL) in China was unclear. A prospective study was conducted to quantify the medical cost burden of NIs among AL patients.

METHODS

Nine hundred ninety-four patients diagnosed with AL between January 2011 and December 2013 were included. Relevant necessary information was extracted from the hospital information system and hospital infection surveillance system. The primary outcome was incidence of NIs and the secondary was economic burden results, including extra medical costs and prolonged length of stay (LOS). We estimated the total incremental cost of NIs by comparing all-cause health care costs in patients with versus without infections. Prolonged duration of stay was compared in patients with different infections.

RESULTS

Of 994 patients with AL, 277 (27.9%) experienced NIs. NI was associated with a total incremental cost of $3,092 per patient ($5,227 vs $2,135; P < .01) and infected patients experienced a longer LOS (21 vs 10 days; P < .01). Patients with multisite infection had the highest total medical cost ($8,474.90 vs $2,209.90; P < .01) and the longest LOS (25 vs 15 days; P < .01). Western medicine was the main contributor to the rise of total cost in all kinds of infections.

CONCLUSIONS

NI was associated with higher medical costs, which imposed an economic burden on patients with AL. The study highlights the influence of NIs on LOS and health care costs and appeal to the establishment of prophylactic measures for NIs to reduce the unnecessary waste of medical resources in the long run.

Variability of anti-staphylococcal antibodies in healthy volunteers and pre-cardiac surgery patients

Background

Pre-operative antibody levels have been shown to be inversely related to development of post-operative complications. Staphylococcal infection is a major source of morbidity following surgery.

Methods

We examined the variability of anti-staphylococcal antibody levels across a group of healthy volunteers and compared this with patients scheduled to undergo cardiac surgery.

Results

Pre-operative cardiac surgical patients exhibited significantly higher levels of staphylococcal antibodies compared with healthy volunteers.

Conclusions

The relationship between pre-surgery staphylococcal antibody levels and outcome warrants further investigation.

A nonparametric approach for optimal reliability allocation in health services

Purpose

– Reliability evaluation of healthcare services has been a challenging task for both operations managers and system engineers working in the respective field. The purpose of this paper is to develop a data envelopment analysis-based reliability allocation model.

Design/methodology/approach

– A two-phase optimization scheme for the reliability evaluation and allocation of homogeneous system entities, namely, hospitals, operating in a healthcare network is proposed. First, reliability evaluation is performed nonparametrically through the frontier estimation technique data envelopment analysis by considering several failure modes and failure free discharged patients as the inputs and output of the service system. Subsequently, optimal reliability allocation that maximizes the overall network reliability subject to a budget constraint is carried out by utilizing weights of the inputs and output calculated on the Pareto optimal frontier, which is constructed from the most reliable hospitals operating in the network.

Findings

– The popular performance assessment methodology DEA is found to be an invaluable reliability assessment and allocation tool, where optimal weights of the associated envelopment model, under certain budget restrictions, are used to maximize overall network reliability.

Originality/value

– An empirical illustration of the proposed model is presented on a set of hospital network data from Turkey. Modeling implications can be carried out on similar service operations where identification of the critical performance indicator costs is possible.

Surgical clothing systems in laminar airflow operating room: a numerical assessment

This study compared two different laminar airflow distribution strategies - horizontal and vertical - and investigated the effectiveness of both ventilation systems in terms of reducing the sedimentation and distribution of bacteria-carrying particles. Three different staff clothing systems, which resulted in source strengths of 1.5, 4 and 5 CFU/s per person, were considered. The exploration was conducted numerically using a computational fluid dynamics technique. Active and passive air sampling methods were simulated in addition to recovery tests, and the results were compared. Model validation was performed through comparisons with measurement data from the published literature. The recovery test yielded a value of 8.1 min for the horizontal ventilation scenario and 11.9 min for the vertical ventilation system. Fewer particles were captured by the slit sampler and in sedimentation areas with the horizontal ventilation system. The simulated results revealed that under identical conditions in the examined operating room, the horizontal laminar ventilation system performed better than the vertical option. The internal constellation of lamps, the surgical team and objects could have a serious effect on the movement of infectious particles and therefore on postoperative surgical site infections.

Evaluating the optimal timing of surgical antimicrobial prophylaxis: study protocol for a randomized controlled trial

BACKGROUND

Surgical site infections are the most common hospital-acquired infections among surgical patients. The administration of surgical antimicrobial prophylaxis reduces the risk of surgical site infections . The optimal timing of this procedure is still a matter of debate. While most studies suggest that it should be given as close to the incision time as possible, others conclude that this may be too late for optimal prevention of surgical site infections. A large observational study suggests that surgical antimicrobial prophylaxis should be administered 74 to 30 minutes before surgery. The aim of this article is to report the design and protocol of a randomized controlled trial investigating the optimal timing of surgical antimicrobial prophylaxis.

METHODS/DESIGN

In this bi-center randomized controlled trial conducted at two tertiary referral centers in Switzerland, we plan to include 5,000 patients undergoing general, oncologic, vascular and orthopedic trauma procedures. Patients are randomized in a 1:1 ratio into two groups: one receiving surgical antimicrobial prophylaxis in the anesthesia room (75 to 30 minutes before incision) and the other receiving surgical antimicrobial prophylaxis in the operating room (less than 30 minutes before incision). We expect a significantly lower rate of surgical site infections with surgical antimicrobial prophylaxis administered more than 30 minutes before the scheduled incision. The primary outcome is the occurrence of surgical site infections during a 30-day follow-up period (one year with an implant in place). When assuming a 5% surgical site infection risk with administration of surgical antimicrobial prophylaxis in the operating room, the planned sample size has an 80% power to detect a relative risk reduction for surgical site infections of 33% when administering surgical antimicrobial prophylaxis in the anesthesia room (with a two-sided type I error of 5%). We expect the study to be completed within three years.

DISCUSSION

The results of this randomized controlled trial will have an important impact on current international guidelines for infection control strategies in the hospital. Moreover, the results of this randomized controlled trial are of significant interest for patient safety and healthcare economics.

TRIAL REGISTRATION

This trial is registered on ClinicalTrials.gov under the identifier NCT01790529.

Preoperative antiseptic skin preparations and reducing SSI

Surgical site infection (SSI) can affect the quality of care and increase the morbidity and mortality rate in after-surgical procedure. The use of an antiseptic skin preparation agent before the procedure can reduce the pathogens in the skin surface around the incision. Indicating the type of skin antiseptic preparation could prevent the infection and contamination of the wound. The most commonly used types of skin preparations are chlorhexidine and povidone iodine. However, the antiseptic solutions of both agents are strengthened with alcohol to prevent postoperative wound infection. The aim of this paper is to identify the best antiseptic agent in terms of skin preparation by evaluating the evidence in the literature. The factors associated with choosing the antiseptic skin agent, such as patients' allergies, skin condition and environmental risk, are also taken into account. This review suggests that cholorhexdine with alcohol may be the most effective in terms of reducing SSI.

Hand hygiene compliance in transplant and other special patient groups: an observational study

BACKGROUND

This study evaluates hand hygiene behavior of health care workers in a German university hospital stratified for treatment of special patient groups (eg, transplant patients).

METHODS

From 2008 to 2010, comprehensive education and training of all health care workers was implemented to improve hand hygiene compliance. Consumption rates of alcohol-based hand rub and gloves were collected and evaluated.

RESULTS

Of the 5,647 opportunities of hand disinfection evaluated, 1,607 occurred during care for transplant patients. To our knowledge, this is the largest survey of hand hygiene compliance in special patient groups on intensive care units in a university hospital in Germany. Health care workers on surgical intensive care units showed lower hand hygiene compliance compared with health care workers on other types of intensive care units. Compliance toward hand hygiene was significantly higher on hemato-oncologic and pediatric wards. In general, hand disinfection was performed significantly more frequently after an intervention than before (P < .05, 95% confidence interval: 1.24-1.84). Overall, there was no significant difference in hand hygiene compliance when caring for transplant patients or other patients (odds ratio, 1.16; 95% confidence interval: 0.95-1.42). Nurse's and physician's hand hygiene compliance improved because of education.

CONCLUSION

Hand hygiene compliance is not increased in the care for transplant patients (despite their predisposition for nosocomial infections) compared with other patients. Additional studies will be necessary to further investigate these findings.

Epidemiology and outcome of major postoperative infections following cardiac surgery: risk factors and impact of pathogen type

BACKGROUND

Major postoperative infections (MPIs) are poorly understood complications of cardiac surgery. We examined the epidemiology, microbiology, and outcome of MPIs occurring after cardiac surgery.

METHODS

The study cohort was drawn from the Society of Thoracic Surgeon National Cardiac Database and comprised adults who underwent cardiac surgery at 5 tertiary hospitals between 2000 and 2004. We studied the incidence, microbiology, and risk factors of MPI (bloodstream or chest wound infections within 30 days after surgery), as well as 30-day mortality. We used multivariate regression analyses to evaluate the risk of MPI and mortality.

RESULTS

MPI was identified in 341 of 10,522 patients (3.2%). Staphylococci were found in 52.5% of these patients, gram-negative bacilli (GNB) in 24.3%, and other pathogens in 23.2%. High body mass index, previous coronary bypass surgery, emergency surgery, renal impairment, immunosuppression, cardiac failure, and peripheral/cerebrovascular disease were associated with the development of MPI. Median postoperative duration of hospitalization (15 days vs 6 days) and mortality (8.5% vs 2.2%) were higher in patients with MPIs. Compared with uninfected individuals, odds of mortality were higher in patients with S aureus MPIs (adjusted odds ratio, 3.7) and GNB MPIs (adjusted odds ratio, 3.0).

CONCLUSIONS

Staphylococci accounted for the majority of MPIs after cardiac surgery. Mortality was higher in patients with Staphylococcus aureus- and GNB-related MPIs than in patients with MPIs caused by other pathogens and uninfected patients. Preventive strategies should target likely pathogens and high-risk patients undergoing cardiac surgery.

Costs of hospital-acquired infection and transferability of the estimates: a systematic review

Hospital-acquired infections (HAIs) present a substantial problem for healthcare providers, with a relatively high frequency of occurrence and considerable damage caused. There has been an increase in the number of cost-effectiveness and cost-savings analyses of HAI control measures, and the quantification of the cost of HAI (COHAI) is necessary for such calculations. While recent guidelines allow researchers to utilize COHAI estimates from existing published literature when evaluating the economic impact of HAI control measures, it has been observed that the results of economic evaluations may not be directly applied to other jurisdictions due to differences in the context and circumstances in which the original results were produced. The aims of this study were to conduct a systematic review of published studies that have produced COHAI estimates from 1980 to 2006 and to evaluate the quality of these estimates from the perspective of transferability. From a total of 89 publications, only eight papers (9.0%) had a high level of transferability in which all components of costs were described, data for costs in each component were reported, and unit costs were estimated with actual costing. We also did not observe a higher citation level for studies with high levels of transferability. We feel that, in order to ensure an appropriate contribution to the infection control program decision-making process, it is essential for researchers who estimate COHAI, analysts who use COHAI estimates for decision-making, as well as relevant journal reviewers and editors to recognize the importance of a transferability paradigm.

Building a successful infection prevention program: key components, processes, and economics

Infection control is the discipline responsible for preventing nosocomial infections. There has been an increasing focus on prevention rather than control of hospital-acquired infections. Individuals working in infection control have seen their titles change from infection control practitioner to infection control professional and most recently to infection preventionist (IP), emphasizing their critical role in protecting patients. The responsibilities of IPs span multiple disciplines including medicine, surgery, nursing, occupational health, microbiology, pharmacy, sterilization and disinfection, emergency medicine, and information technology. This article discusses the structure and responsibilities of an infection control program and the regulatory pressures and opportunities the program faces.

Surgical site infections--economic consequences for the health care system

PURPOSES

Unfortunately, surgical site infections (SSIs) are a quite common complication and represent one of the major causes of postoperative morbidity and mortality, and may furthermore lead to enormous additional costs for hospitals and health care systems.

METHODS

In order to determine the estimated costs due to SSIs, a MEDLINE search was performed to identify articles that provide data on economic aspects of SSIs and compared to findings from a matched case-control study on costs of SSIs after coronary bypass grafting (CABG) in a German tertiary care university hospital.

RESULTS

A total of 14 studies on costs were found. The additional costs of SSI vary between $3,859 (mean) and $40,559 (median). Median costs of a single CABG case in the recently published study were $49,449 (€36,261) vs. $18,218 (€13,356) in controls lacking infection (p < 0.0001). The median reimbursement from health care insurance companies was $36,962 (€27,107) leading to a financial loss of $12,482 (€9,154) each.

CONCLUSION

Costs of SSIs may almost triple the individual overall health care costs and those additional charges may not be sufficiently covered. Appropriate measures to reduce SSI rates must be taken to improve the patient's safety. This should also diminish costs for health care systems which benefits the entire community.

Discharge after discharge: predicting surgical site infections after patients leave hospital

In this population-based retrospective cohort study, we examined the frequency, severity, and prediction of post-discharge surgical site infections (SSIs). We evaluated all patients admitted for their first elective surgical procedure in Ontario, Canada, between 1 April 2002 and 31 March 2008. Procedure and patient characteristics were derived from linked hospital, emergency room and physician claims databases within Canada's universal healthcare system. The 30 day risk of SSI was derived from the initial hospital admission, outpatient consultations, return emergency room visits and readmissions. The cohort included 622 683 patients, of whom 84 081 (13.5%) were diagnosed with SSI, and more than half (48 725) were diagnosed post-discharge. Post-discharge infections were associated with an increased risk of reoperation (odds ratio: 2.28; 95% confidence interval: 2.11-2.48), return emergency room visit (9.08; 8.89-9.27), and readmission (6.16; 5.98-6.35). The most common risk index predicted incremental increases in the risk of in-hospital SSI, but did not predict increases in the risk of post-discharge infection. Patients with post-discharge infections had baseline characteristics more akin to uninfected patients than patients with in-hospital infections. Predictors of post-discharge infection included shorter procedure duration, shorter length of stay, rural residence, alcoholism, diabetes and obesity. Post-discharge SSIs are frequent, severe, scattered over time and location, and hard to predict using common risk indices. They represent an important hidden burden in our healthcare system.

Attributable costs of surgical site infection and endometritis after low transverse cesarean delivery

BACKGROUND

Accurate data on costs attributable to hospital-acquired infections are needed to determine their economic impact and the cost-benefit of potential preventive strategies.

OBJECTIVE

To determine the attributable costs of surgical site infection (SSI) and endometritis (EMM) after cesarean section by means of 2 different methods.

DESIGN

Retrospective cohort.

SETTING

Barnes-Jewish Hospital, a 1,250-bed academic tertiary care hospital.

PATIENTS

There were 1,605 women who underwent low transverse cesarean section from July 1999 through June 2001.

METHODS

Attributable costs of SSI and EMM were determined by generalized least squares (GLS) and propensity score matched-pairs by means of administrative claims data to define underlying comorbidities and procedures. For the matched-pairs analyses, uninfected control patients were matched to patients with SSI or with EMM on the basis of their propensity to develop infection, and the median difference in costs was calculated.

RESULTS

The attributable total hospital cost of SSI calculated by GLS was $3,529 and by propensity score matched-pairs was $2,852. The attributable total hospital cost of EMM calculated by GLS was $3,956 and by propensity score matched-pairs was $3,842. The majority of excess costs were associated with room and board and pharmacy costs.

CONCLUSIONS

The costs of SSI and EMM were lower than SSI costs reported after more extensive operations. The attributable costs of EMM calculated by the 2 methods were very similar, whereas the costs of SSI calculated by propensity score matched-pairs were lower than the costs calculated by GLS. The difference in costs determined by the 2 methods needs to be considered by investigators who are performing cost analyses of hospital-acquired infections.

Risk-adjusted increases in medical resource utilization associated with health care-associated infections in gastrectomy patients

RATIONALE, AIMS AND OBJECTIVES

Quantifying the impact of health care-associated infections (HAIs) on medical resource utilization is necessary for payers and providers to appropriately allocate limited resources for interventions. However, previous studies tend to involve single institutions and do not take into account patient and practice variations between several hospitals. The objective of this study was to conduct a multi-institutional risk-adjusted comparison of HAI-associated impact on medical resources in gastrectomy patients in Japan.

METHODS

Health care-associated infections were identified using a combination of International Classification of Diseases-10 codes and antibiotic utilization patterns in 1058 gastrectomy patients from 10 Japanese hospitals. Multiple linear regression models and risk adjustment were used to analyse the impact of HAIs on: (1) total hospital costs; (2) antibiotic costs; and (3) post-surgical length of stay (LOS).

RESULTS

Overall HAI incidence for the database was 20.3%, with a range of 8.8-29.6% among the 10 hospitals. Regression models showed that HAIs were significantly associated with increases in all three indicators. Risk-adjusted comparisons revealed that HAIs were associated with an increase of US$2767 (range: US$1035-6513) in overall hospital cost, US$202 (US$98.8-764.6) antibiotic costs and 10.6 (4.7-24 days) post-surgical LOS days.

CONCLUSIONS

Even after adjusting for patient characteristics and other variables, there was still a high degree of variation observed in the impact of HAIs on total hospital costs and antibiotic costs from a third-party payer's perspective and post-surgical LOS among the 10 hospitals. This information can increase the efficiency of allocation of resources for interventions to reduce HAIs.

Incidence of and preoperative risk factors for Staphylococcus aureus bacteremia and chest wound infection after cardiac surgery

OBJECTIVE

Staphylococcus aureus infections after cardiac surgery result in significant morbidity and mortality. Identifying patients at elevated risk for these infections preoperatively could facilitate efforts to reduce infection rates. The objectives of this study were to estimate the incidence of postoperative S. aureus infections in cardiac surgery patients, to identify preoperative risk factors for these infections, and to establish a patient risk profile by means of data available to clinicians prior to surgery.

DESIGN

Cohort study.

SETTING

Eight medical centers that participate in the Society of Thoracic Surgeons National Cardiac Database.

PATIENTS

Patients who were undergoing elective cardiac surgery during the period January 1, 2000 through December 31, 2004.

METHODS

Clinical and microbiological data from 16,386 patients were combined. Multivariable stepwise logistic regression analysis was performed to predict S. aureus infection, which was defined by culture results.

RESULTS

Of the 16,386 patients, 205 (1.3%) developed S. aureus bloodstream or chest wound infection within 90 days after surgery. On multivariable analysis, bootstrap-validated preoperative risk factors for S. aureus bloodstream or chest wound infection included a body mass index greater than 40 (adjusted odds ratio [aOR], 1.9 [95% confidence interval {CI}, 1.1-3.2]), chronic renal failure (aOR, 1.8 [95% CI, 1.1-2.9]), and chronic lung disease (aOR, 1.4 [95% CI, 1.0-2.0]). Only 8 patients had all 3 risk factors.

CONCLUSIONS

Although preoperative risk factors can be easily identified, the majority of patients who developed S. aureus infections after cardiac surgery did not have any risk factors. Preventive measures should not be restricted to a select group of cardiac surgery patients and should rather address the entire patient population.

Surgical site infections: how high are the costs?

There is an increased interest in prevention of nosocomial infections and in the potential savings in healthcare costs. The aim of this review of recent studies on surgical site infections (SSIs) was to compare methods of cost research and magnitudes of costs due to SSI. The studies reviewed differ greatly with regard to study design and methods for cost calculation. However, healthcare costs for a patient with SSI are, on average, approximately twice the amount of costs for a patient without an SSI.

Estimating nursing costs--a methodological review

A critical cost accounting issue relating to nursing costs is that nursing costs are currently averaged into the daily room rate in the hospitals. This accounting practice treats nursing units as cost centers as nursing costs are bundled into a per diem rate instead of billed separately. As a result, all patients in a given care unit of the hospital are presumed to consume the same amount of nursing care resources. This costing and billing system creates a mismatch between resources consumption and billed charges. The objective of this paper is to (1) demonstrate current practice to estimate nursing costs, (2) classify nursing costs into direct and indirect costs in order to refine the existing approaches and (3) argue that a system of billing nursing costs separately better reflects the costs of patient care.

[Surveillance of surgical site infections after digestive surgery]

OBJECTIVE

The authors had for aim to monitor surgical site infections (SSI) after digestive surgery and to compare local hospital rates to those of the south-east French region. The overall rate of SSI was compared to the rate of two targeted surgeries: cholecystectomy and hernia repair (CHOL, HERN).

METHOD

Surveillance of all surgical procedures, following "CCLIN Sud-Est" surveillance guidelines was carried out between June and August 2006.

RESULTS

Three hundred and thirty-eight surgeries were included. Among them, 20 SSIs (5.92%) were diagnosed and confirmed by a surgeon. The univariate analysis identified six risk factors: age, wound classes (3 or 4), ASA (3 or 4 or 5), length of surgery (greater than two hours), complexity of surgery, and carcinologic surgery. In the multivariate analysis, ASA score and length of surgery were significantly linked to SSI. SSI rates for HERN and CHOL were respectively 2.7 (2/73) and 2.9% (2/68).

CONCLUSION

The overall rate of infection was high compared to the "CCLIN Sud-Est" 2005 data. However, teaching hospitals accounted for only 8% of all interventions and they usually hospitalize patients at risk. Thus, the overall follow-up requires stratifying the results in homogeneous groups of patients (NNIS) to have comparable results overtime and between hospitals. In addition, this monitoring is difficult to perform because it is a very time-consuming routine. However, if CHOL and HERN are more reliable for comparison and less time-consuming, they do not reflect the overall rate of SSI.

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.

Raising standards while watching the bottom line: making a business case for infection control

While society would benefit from a reduced incidence of nosocomial infections, there is currently no direct reimbursement to hospitals for the purpose of infection control, which forces healthcare institutions to make economic decisions about funding infection control activities. Demonstrating value to administrators is an increasingly important function of the hospital epidemiologist because healthcare executives are faced with many demands and shrinking budgets. Aware of the difficulties that face local infection control programs, the Society for Healthcare Epidemiology of America (SHEA) Board of Directors appointed a task force to draft this evidence-based guideline to assist hospital epidemiologists in justifying and expanding their programs. In Part 1, we describe the basic steps needed to complete a business-case analysis for an individual institution. A case study based on a representative infection control intervention is provided. In Part 2, we review important basic economic concepts and describe approaches that can be used to assess the financial impact of infection prevention, surveillance, and control interventions, as well as the attributable costs of specific healthcare-associated infections. Both parts of the guideline aim to provide the hospital epidemiologist, infection control professional, administrator, and researcher with the tools necessary to complete a thorough business-case analysis and to undertake an outcome study of a nosocomial infection or an infection control intervention.

Triclosan-coated sutures for the reduction of sternal wound infections: economic considerations

BACKGROUND

Sternal wound infections are a major complication after cardiac surgery in terms of morbidity and cost increase. To decrease the incidence of infection, we evaluated triclosan-coated sutures for the closure of the sternal incision, as it is known that most of the surgical site infections are related to the incision site.

METHODS

From May to December 2005, a total of 479 patients underwent a cardiac surgical procedure. From those, 103 patients were closed with triclosan-coated suture material (cost per patient $30 [in United States dollars]), whereas the remaining 376 patients had their incision closed with noncoated sutures (cost per patient $21).

RESULTS

During the study period, 24 patients had superficial (n = 10) or deep (n = 14) sternal wound infections (cost per patient $11,200). All those patients were closed with conventional suture material. In the triclosan group, no wound infection or dehiscence was observed during hospital stay and follow-up visits.

CONCLUSIONS

Triclosan-coated sutures might be valuable in the reduction of sternal wound infections and avoid the suture being a risk factor for surgical site infections. The increased cost of the coated suture material has to be weighed against the enormous cost of sternal wound infections caused directly by the cost of care as well as indirectly through the loss of economic productivity.

Sternal wound infection after coronary artery bypass graft surgery: Validation of existing risk scores

OBJECTIVE

Prediction of surgical site infection and mortality after cardiac surgery might allow for interventions to reduce adverse outcomes. We sought to evaluate existing risk scores.

METHODS

We included 809 consecutive patients undergoing coronary artery bypass surgery. Data were collected prospectively. Infections were defined as deep sternal wound infection or mediastinitis by using established criteria and evaluated 60 days after surgical intervention. All-cause mortality was assessed at 30 days and 6 months. We assessed the ability of the National Nosocomial Infections Surveillance risk index, the EuroSCORE, and the Society of Thoracic Surgeons risk score to predict infection and mortality. Discrimination was assessed using the area under the receiver operating curve.

RESULTS

The rate of surgical site infection was 3.6% (29/809 patients). The National Nosocomial Infections Surveillance risk index showed moderate discrimination for infection (area under the receiver operating curve of 0.64) and poor ability to stratify patients into infection risk groups. The EuroSCORE predicted infection and 30-day and 6-month mortality with good discrimination (area under the receiver operating curve of 0.72, 0.78, and 0.77, respectively). Ranking patients by the EuroSCORE and dividing the cohort into 3 roughly equal risk groups yielded an ascending risk for infection of 0.7%, 3.0%, and 7.2%. The preoperative and intraoperative Society of Thoracic Surgeons risk scores showed good discrimination for surgical site infection (area under the receiver operating curve of 0.72 and 0.76, respectively) and excellent discrimination for early and late mortality (area under the receiver operating curve of >0.80). Risk grouping based on the Society of Thoracic Surgeons score yielded an ascending risk for infection of 0.7%, 3.6%, and 6.4%.

CONCLUSIONS

The EuroSCORE and the Society of Thoracic Surgeons risk score can be used for joint risk stratification for surgical site infection and mortality. Both scores performed better than the National Nosocomial Infections Surveillance risk index.