Interhospital Comparison of Surgical Site Infection Rates in Orthopedic Surgery

Validation of the first computerized indicator for orthopaedic surgical site infections in France: ISO-ORTHO

BACKGROUND

The French national authority for health (HAS) develops in-hospital indicators for improving quality of care, safety and patient outcome. Since 2017, it has developed a measurement of surgical site infections (SSI) after total hip or knee arthroplasty (TH/KA) by using a computerized indicator, called ISO-ORTHO, based on a hospital discharge database (HDD) algorithm. The aim of the study was to assess the performance of this new indicator .

METHODS

The ISO-ORTHO performance was estimated via its positive predictive value (PPV) among adult patients having undergone a TH/KA between January 1st and September 30th 2018, based on the orthopaedic procedure codes. Patients at very high risk of SSI and/or with SSI not related to the in-hospital care were excluded. SSI were detected from the date of admission up to 90 days after the TH/KA using the ISO-ORTHO algorithm, based on 15 combinations of ICD-10 and procedure codes. Its PPV was estimated by a chart review in volunteer healthcare organisations (HCO).

RESULTS

Over the study period, 777 HCO including 143,227 TH/KA stays were selected, providing 1,279 SSI according to the ISO-ORTHO indicator. The 90-day SSI rate was 0.89 per 100 TH/KA stays (0.98% for THA and 0.80% for TKA). Among the 448 HCO with at least 1 SSI, 250 HCO participated in reviewing 725 SSI charts; 665 were confirmed, giving a PPV of 90.3% [88.2-92.5%], 89.9% [87.1-92.8%] in THA and 90.9% [87.7-94.2%] in TKA.

CONCLUSIONS

The PPV of ISO-ORTHO over 90% confirms its validity for any use according to the HAS method. ISO-ORTHO and detailed information were provided in 2020 to HCO and used for quality assessment and in-hospital risk management.

Plan-Do-Check-Action Circulation Combined with Accelerated Rehabilitation Nursing under Computed Tomography in Prevention and Control of Hospital Infection in Elderly Patients Undergoing Elective Orthopedic Surgery

To explore the adoption of plan-do-check-action (PDCA) circulation combined with accelerated rehabilitation nursing based on gemstone spectral imaging computed tomography (GSICT) in the prevention and control of hospital infection in the elderly patients undergoing the elective orthopedic surgery, 80 elderly patients who underwent the elective orthopedic surgery in the hospital were selected. Then, according to the randomized controlled principle, these 80 patients were divided into control group (40 cases) with conventional nursing and observation group (40 cases) with accelerated rehabilitation surgical nursing combined with PDCA circulation. All the patients underwent the GSICT examination without any contraindicators. Compared with the conventional CT scan, metal artifacts in GSICT were considerably reduced. In the images processed by GSI and metal artifacts reduction system (MARS), metal artifacts were basically eliminated and the positions, forms, and edges of metal artifacts in the human body were clearly presented. Hospital infection occurred in 1 (2.5%) patient in the observation group and 5 (12.5%) patients in the control group, and the difference was statistically significant (P < 0.05). In terms of temperature increase, patients in control group (37.5%) had a remarkably higher value than that of observation group (7.5%). The increase rate of white blood cell (WBC) count in control group (12.5%) was obviously higher than that in observation group (2.5%). Besides, the differences were statistically significant (P < 0.05). After PDCA circulation combined with accelerated rehabilitation nursing mode was applied, the hospitalization time of observation group (5.3 ± 2.4 days) was markedly lower than that of control group (9.7 ± 3.8 days). Moreover, the total hospitalization cost of observation group (791.44 yuan) was notably lower than that of control group (4068.96 yuan), with significant differences (P < 0.05). Nursing satisfaction in observation group (92.5%) was higher than that in control group (77.5%), and the difference was statistically significant (P < 0.05). In short, GSICT could effectively reduce beam hardening artifacts and metal implant artifacts and improve image quality. Furthermore, accelerated rehabilitation nursing combined with PDCA circulation could effectively reduce the incidence of hospital infection and improve nursing satisfaction.

International comparison of variation in performance between hospitals for THA and TKA: Is it even possible? A systematic review including 33 studies and 8 arthroplasty register reports

In order to improve care for total hip and knee arthroplasties (THA/TKA), hospitals may want to compare their performance with hospitals in other countries. Pooling data across countries also enable early detection of infrequently occurring safety issues. We therefore aimed to assess the between-hospital variation and definitions used for revision, readmission, and complications across countries.

PubMed, Embase, Web of Science, Cochrane library, Emcare, and Academic Search Premier were searched from January 2009 to August 2020 for studies reporting on: (i) primary THA/TKA; (ii) revision, readmission, or complications; and (iii) between-hospital variation. Most recent registry reports of Network of Orthopedic Registries of Europe members were also reviewed. Two reviewers independently screened records, extracted data, and assessed the risk of bias using the Integrated quality Criteria for the Review Of Multiple Study designs tool for studies and relevant domains for registries. We assessed agreement for the following domains: (i) outcome definition; (ii) follow-up and starting point; (iii) case-mix adjustment; and (iv) type of patients and hospitals included.

Between-hospital variation was reported in 33 (1 high-quality, 13 moderate-quality, and 19 low-quality) studies and 8 registry reports. The range of variation for revision was 0–33% for THA and 0–27% for TKA varying between assessment within hospital admission until 10 years of follow-up; for readmission, 0–40% and 0–32% for THA and TKA, respectively; and for complications, 0–75% and 0–50% for THA and TKA, respectively. Indicator definitions and methodological variables varied considerably across domains.

The large heterogeneity in definitions and methods used likely explains the considerable variation in between-hospital variation reported for revision, readmission, and complications , making it impossible to benchmark hospitals across countries or pool data for earlier detection of safety issues. It is necessary to collaborate internationally and strive for more uniformity in indicator definitions and methods in order to achieve reliable international benchmarking in the future.

Operating room architecture is not a risk factor for surgical site infections

Surgical site infection (SSI) may cause a substantial burden for patients and healthcare systems. A potential risk of different architectures of the operating room for SSI is yet unknown and was subject of this study. This observational cohort study was performed in a university hospital and evaluated patients, who underwent a broad spectrum of orthopedic surgeries in 2016 (open-plan operating room architecture) versus (vs) 2017 (closed-plan operating room architecture). Patients, who underwent surgery in the transition time period from the open-plan to the closed-plan operating room architecture and those, who were treated e.g. for osteomyelitis as index procedure were excluded. The primary outcome was revision surgery for early SSI within 30 (superficial) or 90 (deep or organ/space) days of surgery. Age, gender, American society of anesthesiologists (ASA) classification, and the body mass index (BMI) were considered as potential interacting factors in a logistic regression analysis. The incidence of revisions for SSI was 0.6 percent (%) (n = 45) in the 7'740 included surgical cases (mean age of 52 (standard deviation (SD) 19) years; n = 3'835 (50%) females). There was no difference in incidences of revision for SSI in the open- vs closed-plan operating room architecture (0.5% vs 0.7%; adjusted odds ratio (OR) = 1.34 (95% confidence interval (CI) 0.72-2.49, P = 0.35)). Age and gender were not a risk factor for revision for SSI. However, ASA classification and BMI were identified as risk factors for the incidence of revision for SSI (OR = 1.92 (95% CI 1.16- 3.18, P = 0.01) and OR = 1.05 (95% CI 1.00-1.11, P = 0.05)). The overall incidence of revisions for early SSI after a broad spectrum of orthopedic surgeries was relatively low (0.6%) and independent from the operating room architecture. An increase in ASA classification and possibly BMI, however, were identified as independent risk factors for revision for SSI.

Surgical site infections following hip and knee arthroplastic surgery: Trends and risk factors of Staphylococcus aureus infections

We investigated surgical site infections (SSIs) following hip and knee arthroplasties to evaluate predictors of SSI. We found a significant increase in deep Staphylococcus aureus (SA) SSIs despite the decreasing overall SSI rate. The risk of deep SA-SSI differed between genders and among age groups and was affected by timing of surgery.

[Prevention of postoperative infections : Risk factors and the current WHO guidelines in musculoskeletal surgery]

BACKGROUND

Despite the many scientific and technological advances postoperative infection continues to be a large problem for trauma and orthopedic surgeons. Based on a review of the current literature, this study provides a comprehensive overview of the risk factors (RF) and possible preventive measures to control surgical site infections.

METHODS

Medline search and analysis from 1968-2017 (as of 01 March 2017). Selection of trauma and orthopedic relevant RFs and comparison with WHO recommendations (global guidelines for the prevention of surgical site infection, Nov. 2016).

RESULTS

Identification of 858 relevant articles from the last 50 years (1968-2017). Pooled postoperative rate of infection is 0.3% (hand surgery) and 19% (3rd degree open fractures). For open fractures, there is no clear tendency towards lower infection rates during the past five decades. Identification of 115 RF from three areas (patient-dependent RF, organizational and procedural RF, trauma- and surgery-dependent RF). The five most important RFs are body mass index over 35 kg/m², increased duration of surgery, diabetes mellitus, increased blood glucose levels in the perioperative period also in the case of nondiabetic patients, and errors in the perioperative antibiotic prophylaxis.

DISCUSSION

Inconsistent definition of "infection", interaction of the RF and the different follow-up duration limit the meaningfulness of the study.

CONCLUSION

In the future, considerable efforts must be made in order to achieve a noticeable reduction in the rate of infection, especially in the case of high-risk patients.