Post-discharge surgical site infection surveillance by automated telephony

Usability and outcomes of self-monitored surgical wound healing using a smartphone-based application by patients following neurosurgery

BACKGROUND

The Radboudumc developed a smartphone application (WondGezond) to collect surgical wound-healing information provided by the patient.

AIM

To evaluate usability and outcomes to assess its potential for early surgical site infection (SSI) detection.

METHODS

Patients surgically treated for degenerative spinal disorders or carpal tunnel syndrome between August 2020 and February 2023 were enrolled one day post surgery and asked to download the app via a quick-response (QR) code. Participants uploaded a photo and answered four questions about their wound daily, for 14 days. Afterwards, participants indicated whether they received treatment for a suspected SSI (participant-reported outcome). Two neurosurgeons independently assessed photos and questionnaire answers for suspected SSIs (physician-assessed outcome). The association between both outcomes was determined by calculating sensitivity, specificity, and positive and negative predictive value (PPV/NPV).

FINDINGS

After 2009 surgeries, 1695 QR-codes were distributed and 412 (21%) were activated. In all, 232 (56%) participants completed the 14-day period of whom 22 (10%) reported SSI treatment. Physician assessment identified 15 (7%) SSIs. Concordance was reached in 88% of cases. Among 27 discordant cases were 17 false-positives and 10 false-negatives, resulting in low sensitivity (33%) and PPV (23%), but high NPV (95%).

CONCLUSION

WondGezond provides clinicians with information regarding wound healing and SSIs to follow-up on patients at risk, while possibly also reducing antibiotic (over)treatment and unnecessary visits for patients without issues in wound healing. However, the low participation and false-positive results render the app in its current form unsuitable for surveillance purposes. Further validation of WondGezond is required.

Diagnosing surgical site infections using telemedicine: A Systematic Review

BACKGROUND

Surgical site infections (SSI) are preventable post-operative complications. With the increase in use of telehealth modalities, there is a need to assess if telehealth modalities are safe for assessment of SSI.

AIM

This review aims to assess the accuracy of using telemedicine in the diagnosis of SSI in post-surgical adult patients as compared to in-person assessments.

METHODS

A comprehensive search on 6 databases (PubMed, MEDLINE, Embase, Web of Science, Scopus and CENTRAL) was performed from inception to 1 December 2020. Data was extracted to determine accuracy, feasibility, acceptability, and usability of using telemedicine to detect SSIs. The primary outcome of this review was to review the diagnostic accuracy of telemedicine to diagnose SSIs as compared to direct, in-person assessment. Methodological quality was evaluated using the MINORS criteria.

RESULTS

Six studies met inclusion criteria. Results were summarized qualitatively. The overall methodological quality of the studies was moderate based on the MINORS score. Four studies utilized telephone surveillance, whilst two utilized mobile applications. Telemedicine modalities were able to accurately diagnose 66 SSIs, where an additional 15 were found on direct clinical review. The diagnostic accuracy across the studies ranged from 69.5 to 100%. Between 82.5 and 100% of patients were able to be contacted through these telemedicine modalities.

CONCLUSIONS

Telemedicine modalities are a feasible option for post-operative follow-up, especially in the identification of SSIs. As technology becomes more affordable and widely available, future applications of telemedicine are limitless. However, further research is still required to ensure that telemedicine is a safe and effective tool.

Cost-effectiveness analysis of three methods of surgical-site infection surveillance: Less is more

BACKGROUND

A considerable proportion of surgical site infections (SSI) could be prevented by surveillance. The study aimed to compare the cost-effectiveness of 3 methods of SSI surveillance: Inpatient, phone, and out-patient clinic (OPC); to ensure that the risk of SSI is independent from loss-to-follow-up in phone and OPC surveillances, and to determine the reliability of phone surveillance.

METHODS

A cohort of 351 surgical patients were followed by 3 different surveillance methods: inpatient, follow-up in OPC and over the phone. Costs of nurse time and phone calls were expressed in 2019 USD. Effectiveness of surveillance was assessed using number of detected SSIs.

RESULTS

Phone surveillance was more cost-effective than OPC surveillance. Compared to inpatient surveillance, the OPC method costs USD 15.6 per extra detected SSI, whereas the phone method costs only USD 4.6 In phone and OPC surveillances, the risk of SSI was independent of loss-to-follow-up. However, the higher rate of SSI among OPC attendees raises the suspicion that the incidence of SSI estimated by OPC surveillance could be biased upward. Phone surveillance was reliable with high sensitivity and specificity.

CONCLUSIONS

Phone surveillance was a reliable cost-effective method. Inpatient surveillance was less effective, but it still can be used to detect severe SSI at low cost. While out-patient-clinic surveillance had the highest cost, the incidence estimated by it might be biased upward.

Is telephone follow-up really effective in early diagnosis of inflammatory complications after tooth extraction?

BACKGROUND

To establish whether telephone follow-up is really able to intercept post-extraction complications and to evaluate the degree of patient satisfaction with this kind of post-surgical monitoring.

MATERIAL AND METHODS

six hundred and thirty-eight patients were enrolled and randomly assigned to a test or control group. Test group patients were monitored by telephone follow-up 24 and 72 hours after surgery to investigate the presence of local symptoms that are frequently associated with surgical wound infection and inflammation. Both test and control group patients were examined 7 days at suture removal. Patients with systemic diseases, those in which intra-operative accidents occurred during surgery and those for whom extraction suture was not required, were excluded.

RESULTS

At least one complication among alveolar osteitis, alveolar inflammation, alveolar infection and dehiscence involved 15.70% of the patients in the test group and 30.70% of the patients in the control group and telephone follow-up proved to be useful in early identification of anomalies in the post-extraction wound healing process. Comparable results were recorded in all extraction subgroups divided according to the type (surgical and non-surgical) and the number (single and multiple) of extractions performed in the same session. Telephone follow-up showed an 8.60 ± 1.17 (0 to 10 score scale) average acceptance. All cases of alveolar osteitis and infection occurred in patients who underwent antibiotic prophylaxis.

CONCLUSIONS

Telephone follow-up seems to allow early detection of any possible wound healing complications, it is widely accepted by patients and it could therefore be considered a valid method for wound healing monitoring after tooth extractions, due to its effectiveness, feasibility and low costs.

First Results of the Swiss National Surgical Site Infection Surveillance Program: Who Seeks Shall Find

OBJECTIVES

To report on the results of the Swiss national surgical site infection (SSI) surveillance program, including temporal trends, and to describe methodological characteristics that may influence SSI rates

DESIGN

Countrywide survey of SSI over a 4-year period. Analysis of prospectively collected data including patient and procedure characteristics as well as aggregated SSI rates stratified by risk categories, type of SSI, and time of diagnosis. Temporal trends were analyzed using stepwise multivariate logistic regression models with adjustment of the effect of the duration of participation in the surveillance program for confounding factors.

SETTING

The study included 164 Swiss public and private hospitals with surgical activities.

RESULTS

From October 2011 to September 2015, a total of 187,501 operations performed in this setting were included. Cumulative SSI rates varied from 0.9% for knee arthroplasty to 14.4% for colon surgery. Postdischarge follow-up was completed in >90% of patients at 1 month for surgeries without an implant and in >80% of patients at 12 months for surgeries with an implant. High rates of SSIs were detected postdischarge, from 20.7% in colon surgeries to 93.3% in knee arthroplasties. Overall, the impact of the duration of surveillance was significantly and independently associated with a decrease in SSI rates in herniorraphies and C-sections but not for the other procedures. Nevertheless, some hospitals observed significant decreases in their rates for various procedures.

CONCLUSIONS

Intensive post-discharge surveillance may explain high SSI rates and cause artificial differences between programs. Surveillance per se, without structured and mandatory quality improvement efforts, may not produce the expected decrease in SSI rates.

Infect Control Hosp Epidemiol 2017;38:697–704

[Effect of compliance with an antibiotic prophylaxis protocol in surgical site infections in appendectomies. Prospective cohort study]

BACKGROUND

Antibiotic prophylaxis is the most suitable tool for preventing surgical site infection. This study assessed compliance with antibiotic prophylaxis in surgery for acute appendicitis, and the effect of this compliance on surgical site infection.

MATERIAL AND METHODS

Prospective cohort study to evaluate compliance with antibiotic prophylaxis protocol in appendectomies. An assessment was made of the level of compliance with prophylaxis, as well as the causes of non-compliance. The incidence of surgical site infection was studied after a maximum incubation period of 30 days. The relative risk adjusted with a logistic regression model was used to assess the effect of non-compliance of prophylaxis on surgical site infection.

RESULTS

The study included a total of 930 patients. Antibiotic prophylaxis was indicated in all patients, and administered in 71.3% of cases, with an overall protocol compliance of 86.1%. The principal cause of non-compliance was time of initiation. Cumulative incidence of surgical site infection was 4.6%. No relationship was found between inadequate prophylaxis compliance and infection (relative risk=0.5; 95% CI: 0.1-1.9) (P>.05).

CONCLUSIONS

Compliance of antibiotic prophylaxis was high, but could be improved. No relationship was found between prophylaxis compliance and surgical site infection rate.

Postdischarge surveillance for infection following cesarean section: A prospective cohort study comparing methodologies

OBJECTIVE

To assess how enhanced postdischarge telephone follow-up calls would improve case finding for surgical site infection (SSI) surveillance after cesarean section.

METHODS

We conducted a prospective cohort study of all patients who delivered by cesarean section between April 22 and August 22, 2010. In addition to our routine surveillance, using clinical databases and electronic patient records, we also made follow-up calls to the patients at 7, 14, and 30 days postoperation. A standard questionnaire with questions about symptoms of SSI, health-seeking behaviors, and treatment received was administered. Descriptive statistics and univariate analysis were performed to assess the effect of the enhanced surveillance.

RESULTS

One hundred ninety-three patients underwent cesarean section during this study period. Standard surveillance identified 14 infections with telephone follow-ups identifying an additional 5 infections. Using the call as a gold standard, the sensitivity of the standard methodology to capture SSI was 73.3%. The duration of the calls ranged from 1 to 5 minutes and were well received by the patients.

CONCLUSIONS

Results suggest that follow-up telephone calls to patients following cesarean section identifies 26.3% of the total SSIs. Enhanced surveillance can provide more informed data to enhance performance and avoid underestimation of rates.

Surgical site infection: the principles and practice of surveillance. Part 1: Key concepts in the methodology of SSI surveillance

urgical site infections (SSI) account for a major proportion of healthcare associated infections (HCAI) yet many hospitals capture little data on the risk of SSI in patients undergoing surgery and therefore have little assurance about the quality of infection prevention in their operating departments. This paper is the first part of a two part series that will examine the principles and practice of surveillance of SSI. Part 2 will examine the analysis of SSI data and the use of the results to change practice. This paper reviews the principles that underpin SSI surveillance methodology, key concepts that affect the accuracy of data capture systems and strategies for addressing them, including risk factors and active case finding systems to ensure detection of SSI, including those that develop after discharge from hospital.

Three questions to screen for postdischarge surgical site infections

In-hospital surveillance of surgical site infections (SSI) was conducted on 599 patients in a German university hospital. On a subgroup of 342 patients, SSI was assessed after discharge from hospital based on data of a questionnaire and telephone interviews. Postdischarge surveillance revealed substantially higher infection rates than in-hospital surveillance. From assessment of single questionnaire items, a model of a 3-item questionnaire for surveillance of SSI is proposed.

[Surgical-site infections following varicose vein surgery according to a continuous series of 408 interventions in a teaching hospital]

OBJECTIVE

To determine the incidence of surgical-site infections (SSI) following varicose vein surgery in the vascular surgery ward of a French teaching hospital.

PATIENTS AND METHODS

A prospective surveillance of SSI was conducted during one year, with a 30-day postoperative follow-up. SSI cases were identified by using the definitions of the Centers for Disease Control (CDC, USA). Data acquisition and analysis were performed with the Epi-Info 6.04 software (CDC).

RESULTS

Three quarters of the 408 included interventions were characterized by a NNIS score equal to 0. All patients underwent a hair removing practice before intervention. Hair removing methods were very heterogeneous and often not in accordance with national recommendations (e.g. mechanic shaving for 44.6% of patients). The incidence of SSI was 1.2% (95% confidence interval=[0.2-2.2]). All infections were identified after hospital discharge. Four infected patients out of five presented obesity or excess weight, and two patients had diabetes mellitus. The mean age of infected patients was significantly higher than non-infected ones (70.4 years versus 52.0; p<0.01). All SSI had consequences like rehospitalization, reintervention, or antimicrobial therapy.

CONCLUSION

According to our results, SSI following varicose vein surgery are scarce and mainly concerned high-risk patients. However, in an aim of prevention, it seems necessary to homogenize hair removing methods in this ward.