Reducing the Risk of Surgical Site Infections: Did We Really Think SCIP Was Going to Lead Us to the Promised Land?

Different Surgeon, Different Closure: Lack of Consensus on Appropriate Closure Technique for Various Case Scenarios

Background: Many techniques for closure of surgical incisions are available to the surgeon, but there is minimal guidance regarding which technique(s) should be utilized at the conclusion of surgery and under what circumstances. Hypothesis: Management of incisions at the conclusion of surgery lacks consensus and varies among individual surgeons. Methods: The Surgical Infection Society membership was surveyed on the management of incisions at the conclusion of surgery. Several case scenarios were provided to test the influences of operation type, intra-operative contamination, and hemodynamic stability on incision management (e.g., close fascia or skin, use of incision/wound vacuum-assisted closure [VAC] device). Responses by two-thirds of participants were required to achieve consensus. Data analysis by χ² test and logistic regression, a = 0.05. Response heterogeneity was quantified by the Shannon index (SI). Results: Among 78 respondents, consensus was achieved for elective splenectomy (91% close skin/dry dressing). Open appendectomy and left colectomy/end-colostomy had the greatest heterogeneity (SI, 1.68 and 1.63, respectively). During trauma laparotomy, the majority used damage control for hemodynamic instability (53%-67%) but not for hemodynamically stable patients (0%-1.3%; p < 0.001). Additional consensus was achieved for close skin/dry dressing for hemodynamically stable trauma splenectomy patients (87%) and fascia open/wound VAC for hemodynamically unstable colon resection/anastomosis (67%). Fecal diversion for rectal injury and colon resection/anastomosis (both when hemodynamically stable) had high heterogeneity (SI, 1.56 and 1.48, respectively). In penetrating trauma, sentiment was for more use of wet-to-dry dressings and incision/wound VAC with increased contamination in hemodynamically stable patients. Conclusions: Damage control was favored in hemodynamically unstable trauma patients, with use of wet-to-dry dressings and incision/wound VAC with spillage after penetrating trauma. However, most scenarios did not achieve consensus. High variability of practices regarding incision management at the conclusion of surgery was confirmed. Prospective studies and evidence-based guidance are needed to guide decision making at end-operation.

Potential side effects of antibacterial coatings in orthopaedic implants: A systematic review of clinical studies

Objective: The systematic review aimed to determine the potential side effects of antibacterial coatings in orthopaedic implants. Methods: Publications were searched in the databases of Embase, PubMed, Web of Science and Cochrane Library using predetermined keywords up to 31 October 2022. Clinical studies reporting side effects of the surface or coating materials were included. Results: A total of 23 studies (20 cohort studies and three case reports) reporting the concerns about the side effects of antibacterial coatings were identified. Three types of coating materials, silver, iodine and gentamicin were included. All of studies raised the concerns regarding safety of antibacterial coatings, and the occurrence of adverse events was observed in seven studies. The main side effect of silver coatings was the development of argyria. For iodine coatings, only one anaphylactic case was reported as an adverse event. No systemic or other general side effects were reported for gentamicin. Conclusion: Clinical studies on the side effects of antibacterial coatings were limited. Based on the available outcomes, the most reported side effects of antibacterial coatings in clinical use were argyria with silver coatings. However, researchers should always pay attention to the potential side effects of antibacterial materials, such as systematic or local toxicity and allergy.

Recommendations for change in infection prevention programs and practice

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

A Paradigm Shift in Physician Reimbursement: A Model to Align Reimbursement to Value in Laparoscopic Colorectal Surgery in the United States

BACKGROUND

Despite common beliefs, underuse of laparoscopic colorectal surgery remains an issue. A paradigm shift to increase laparoscopy and align payment with effort is needed, with pressures to improve value.

OBJECTIVE

The purpose of this study was to compare reimbursement across surgical approach and payer for common colorectal procedures and to propose a novel way to increase use in the United States.

DATA SOURCES

Centers for Medicare & Medicaid Services (Medicare) reimbursement and commercial claims data from 2012 to 2015 were used.

STUDY SELECTION

Reimbursement across payers was mapped for the 10 most common colorectal procedures using the open and laparoscopic approaches.

MAIN OUTCOME MEASURES

The reimbursement difference across approaches by payer and potential value proposition from a cost-shifting model increasing reimbursement with corresponding increases in laparoscopic use was measured.

RESULTS

For Medicare, reimbursement was lower laparoscopically than open for the majority. With commercial, laparoscopy was reimbursed less for 3 procedures. When laparoscopic reimbursement was higher, the amount was not substantial. Medicare payments were consistently lower than commercial, with corresponding lower reimbursement for laparoscopy. Increasing reimbursement by 10%, 20%, and 30% resulted in significant cost savings with laparoscopy. Savings were amplified with increasing use, with additional savings over baseline at all levels, except 30% reimbursement/10% increased use.

LIMITATIONS

The study was limited by the use of claims data, which could have coding errors and confounding in the case mix across approaches.

CONCLUSIONS

Reimbursement for laparoscopic colorectal surgery is comparatively lower than open. Reimbursement can be increased with significant overall cost savings, as the reimbursement/case is still less than total cost savings with laparoscopy compared with open cases. Incentivizing surgeons toward laparoscopy could drive use and improve outcomes, cost, and quality as we shift to value-based payment. See Video Abstract at http://links.lww.com/DCR/B290. CAMBIOS EN LOS PARADIGMAS DE REEMBOLSOS MÉDICOS: UN MODELO PARA ALINEAR EL REEMBOLSO AL VALOR REAL DE LA CIRUGÍA COLORRECTAL LAPAROSCÓPICA EN LOS ESTADOS UNIDOS: A pesar de las creencias comunes, la subutilización de la cirugía colorrectal laparoscópica sigue siendo un problema. Se necesita un cambio en los paradigmas para aumentar y alinear el rembolso de la laparoscopia aplicando mucho esfuerzo para obtener una mejoría en su valor real.Comparar los reembolsos del abordaje quirúrgico y los de la administración para procedimientos colorrectales comunes y proponer una nueva forma de aumentar su uso en los Estados Unidos.Reembolsos en los Centros de Servicios de Medicare y Medicaid (Medicare) y los datos de reclamos comerciales encontrados de 2012-2015.El reembolso administrativo se mapeó para los diez procedimientos colorrectales más comunes utilizando los enfoques abiertos y laparoscópicos.Diferencias de reembolso entre los enfoques por parte de la administración y la propuesta de valor real de un modelo de cambio de costos que aumentan el reembolso con los aumentos correspondientes si se utiliza la laparoscopía.Para Medicare, el reembolso fue menor para una mayoría por vía laparoscópica que abierta. Comercialmente, la laparoscopia se reembolsó menos por 3 procedimientos. Cuando el reembolso laparoscópico fue mayor, la cantidad no fue sustancial. Los pagos de Medicare fueron consistentemente más bajos que los pagos comerciales, con el correspondiente reembolso más bajo por laparoscopia. El aumento del reembolso en un 10%, 20% y 30% resultó en ahorros de costos significativos con la laparoscopía. Los ahorros se amplificaron con el aumento de la utilización, con ahorros adicionales sobre la línea de base en todos los niveles, excepto el 30% de reembolso / 10% de mayor uso.Uso de datos de reclamos, que podrían tener errores de codificación y confusión en la combinación de casos entre enfoques.El reembolso por la cirugía colorrectal laparoscópica es comparativamente más bajo que el abordaje abierto. El reembolso se puede aumentar con ahorros significativos en los costos generales, ya que el reembolso / caso es aún menor que el ahorro total en los costos de la laparoscopia en comparación con los casos abiertos. Incentivar a los cirujanos hacia la laparoscopía podría impulsar la utilización y mejorar los resultados, el costo y la calidad a medida que se pasa al pago basado en el valor real. Consulte Video Resumen en http://links.lww.com/DCR/B290. (Traducción-Dr Xavier Delgadillo).

Adherence to surgical antimicrobial prophylaxis: "checking-the-box" is not enough

PURPOSE

The purpose of this paper is to review surgical antimicrobial prophylaxis administration practices in a small cohort and assess compliance with national guidelines.

DESIGN/METHODOLOGY/APPROACH

Patients that developed surgical site infections (SSI) in a tertiary care academic medical center over a two-year period were identified. Their electronic medical records were reviewed for compliance with national guidelines with respect to surgical antibiotic prophylaxis.

FINDINGS

Over a two-year period, 283 SSI patients were identified. An appropriate antibiotic was chosen in 80 percent, an appropriate dose was administered in 45 percent and timing complied in 89 percent. The antibiotics were appropriately re-dosed in only 9.2 percent in whom the requirement was met. The prescribing guidelines were adhered to in entirety in only 54 patients (23.8 percent).

PRACTICAL IMPLICATIONS

Timely and appropriate antibiotic administration prior to surgery is essential to prevent SSI. Proper diligence is required to accomplish this task effectively.

ORIGINALITY/VALUE

Based on the findings, it appears that merely, "checking a box" for antibiotic administration during surgery is not enough, and a multidisciplinary approach should be followed to ensure "appropriate" antibiotic administration.

Public reporting and transparency: a primer on public outcomes reporting

INTRODUCTION

Healthcare consumers seeking accurate information about where to find quality surgical care face a confusing constellation of rating systems that lack transparency or consistency of opinion. For example, a 2016 report in Health Affairs demonstrated that no hospital was rated as a high performer by all four prominent national ratings systems: Consumer Reports, Leapfrog, Healthgrades and U.S. News & World Report (Austin et al. Health Aff 34:423-430, 2015). Surgeons should have an understanding of the current state of public reporting of quality; hospital ratings and data sources; physician ratings and data sources; and transparency of reporting.

METHODS

We conducted a non-systematic review of the literature.

RESULTS

Hospital quality ratings remain nebulous and there is not universal opinion on the utility of voluntary participation in ranking systems, leaving the current systems largely opinion-based. Early attempts at physician ranking systems are rudimentary at best and suffer from methodological concerns. Publicly reported metrics should be easily understandable, accessible, clinically relevant, reliable, non-punitive, and shielded from legal discovery. Transparency is increasing within institutions to help align staff to institutional objectives, while specialty specific registries are helping to standardize care pathways and outcomes measures across organizations. Measuring surgical outcomes beyond 30-day morbidity and mortality has been plagued by a lack of understanding on how to create metrics that matter; the four attributes of relevance, scientific soundness, feasibility and comprehensiveness set a high bar for the development of effective and efficient quality measures in surgery.

DISCUSSION

SAGES, via the Quality, Outcomes, and Safety Committee, is committed to learning how to develop meaningful quality metrics in general surgery and will continue to work in other areas that impact quality, such as opioid prescribing, and surgeon wellness.

The Cost of Surgical Site Infections after Colorectal Surgery in the United States from 2001 to 2012: A Longitudinal Analysis

Surgical site infections (SSIs) are among the most common types of postoperative complications in the United States and are associated with significant prevalence of morbidity and mortality in patients undergoing surgical interventions, especially in colorectal surgery (CRS) where SSI rates are significantly higher than those of similar operative sites. SSIs were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2012 based on the specification of an ICD-9 code. Propensity score matching was used to compare costs associated with SSI cases with those of non-SSI controls among elective and nonelective admissions. Results were projected nationally using Healthcare Cost and Utilization Project sampling methodology to evaluate the incidence of SSIs and ascertain the national cost burden retrospectively. Among 4,851,359 sample-weighted hospitalizations, 4.2 per cent (203,597) experienced SSI. Elective admissions associated with SSI-stayed hospitalized for an average of 7.8 days longer and cost $18,410 more than their counterparts who did not experience an SSI. Nonelective admissions that experienced an SSI had an 8.5-day longer hospital stay and cost $20,890 more than counterparts without perioperative infections. This represents a 3 per cent annual growth in costs for SSIs and seems to be largely driven by cost increases in treatment of SSIs for elective surgeries. Current efforts of SSI management after CRS focused on compliance with guidelines and tracking of infection rates would benefit from some improvements. Considering the growing costs and increase in resource utilization associated with SSIs from 2001 to 2012, further research on costs associated with management of SSIs specific to CRS is necessary.

Coatings as the useful drug delivery system for the prevention of implant-related infections

Implant-related infections (IRIs) which led to a large amount of medical expenditure were caused by bacteria and fungi that involve the implants in the operation or in ward. Traditional treatments of IRIs were comprised of repeated radical debridement, replacement of internal fixators, and intravenous antibiotics. It needed a long time and numbers of surgeries to cure, which meant a catastrophe to patients. So how to prevent it was more important than to cure it. As an excellent local release system, coating is a good idea by its local drug infusion and barrier effect on resisting biofilms which were the main cause of IRIs. So in this review, materials used for coatings and evidences of prevention were elaborated.

Perioperative Antibiotics for Clean Hand Surgery: A National Study

PURPOSE

Given that surgical site infections remain a common performance metric in assessing the quality of health care, we hypothesized that prophylactic antibiotics are overutilized in soft tissue hand surgery when antimicrobials are not indicated.

METHODS

We studied insurance claims from the Truven MarketScan Databases to identify patients who underwent 1 of 5 outpatient hand surgery procedures: open or endoscopic carpal tunnel release, trigger finger release, de Quervain release, and wrist ganglion excision between 2009 and 2015 (n = 305,946). Hospital payment claims for preoperative intravenous antibiotics and prescriptions filled for postoperative oral antibiotics were analyzed. We examined the rate and temporal trend of prophylactic antibiotics use and identified risk factors using multivariable logistic regression. We also calculated health care expenditures related to prophylaxis.

RESULTS

Prior to surgery, 13.6% (2009-2015) of patients received prophylactic intravenous antibiotics and trend analysis showed a statistically significant increase from 2009 (10.6%) to 2015 (18.3%), an increase of 72.5%. Preoperative prophylaxis was used most often prior to trigger finger release (17.5%) and least often prior to endoscopic carpal tunnel release (11.2%). Younger age, male sex, lower income, and obese patients had higher odds of receiving antibiotics. The total charge of prophylactic antibiotics medication used in this study equaled $1.6 million.

CONCLUSIONS

In 2015, prophylactic intravenous antibiotics were administered to nearly 1 in 5 patients prior to clean soft tissue hand surgery. Although consensus guidelines indicate prophylaxis is not indicated, their use has increased steadily in the United States from 2009 to 2015.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Application of a simple, affordable quality metric tool to colorectal, upper gastrointestinal, hernia, and hepatobiliary surgery patients: the HARM score

BACKGROUND

Quality is the major driver for both clinical and financial assessment. There remains a need for simple, affordable, quality metric tools to evaluate patient outcomes, which led us to develop the HospitAl length of stay, Readmission and Mortality (HARM) score. We hypothesized that the HARM score would be a reliable tool to assess patient outcomes across various surgical specialties.

METHODS

From 2011 to 2015, we identified colorectal, hepatobiliary, upper gastrointestinal, and hernia surgery admissions using the Vizient Clinical Database. Individual and hospital HARM scores were calculated from length of stay, 30-day readmission, and mortality rates. We evaluated the correlation of HARM scores with complication rates using the Clavien-Dindo classification.

RESULTS

We identified 525,083 surgical patients: 206,981 colorectal, 164,691 hepatobiliary, 97,157 hernia, and 56,254 upper gastrointestinal. Overall, 53.8% of patients were admitted electively with a mean HARM score of 2.24; 46.2% were admitted emergently with a mean HARM score of 1.45 (p < 0.0001). All HARM components correlated with patient complications on logistic regression (p < 0.0001). The mean length of stay increased from 3.2 ± 1.8 days for a HARM score < 2 to 15.1 ± 12.2 days for a HARM score > 4 (p < 0.001). In elective admissions, for HARM categories of < 2, 2-< 3, 3-4, and > 4, complication rates were 9.3, 23.2, 38.8, and 71.6%, respectively. There was a similar trend for increasing HARM score in emergent admissions as well. For all surgical procedure categories, increasing HARM score, with and without risk adjustment, correlated with increasing severity of complications by Clavien-Dindo classification.

CONCLUSIONS

The HARM score is an easy-to-use quality metric that correlates with increasing complication rates and complication severity across multiple surgical disciplines when evaluated on a large administrative database. This inexpensive tool could be adopted across multiple institutions to compare the quality of surgical care.

A National Study of the Impact of Delayed Flap Timing for Treatment of Patients with Deep Sternal Wound Infection

BACKGROUND

This study aimed to evaluate the impact of delayed flap closure on mortality and resource use for treatment of deep sternal wound infection.

METHODS

The authors analyzed the Truven MarketScan Databases from 2009 to 2013 to identify adult patients who developed deep sternal wound infection after open cardiac surgery and who underwent flap closure for treatment. A multivariable logistic regression model was created to evaluate the relationship between mortality and flap timing. Multivariable Poisson regressions were used to investigate the relationship between flap timing and number of procedures, number of hospitalizations, and length of stay outcomes. A multivariable log-linear regression model was created for cost analysis. All analyses were adjusted for patient risk factors and treatment characteristics.

RESULTS

The authors identified 612 patients with deep sternal wound infection who underwent flap closure. The timing of flap closure was delayed more than 7 days after diagnosis in 39 percent of patients. Delayed time to flap closure greater than 3 days after diagnosis of infection was associated with higher mortality odds for delay 4 to 7 days (OR, 2.94) and delay greater than 7 days (OR, 2.75; p < 0.03), greater additional procedures for delay 4 to 7 days (incidence rate ratio, 1.72) and delay greater than 7 days (incidence rate ratio, 1.93; p < 0.001), and up to 43 percent longer hospital length of stay and 37 percent greater costs compared with patients undergoing flap closure 0 to 3 days after diagnosis.

CONCLUSIONS

Delay in flap closure was associated with greater mortality and resource use. Prompt involvement of reconstructive surgeons may improve quality and efficiency of deep sternal wound infection care.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Perioperative hair removal in the 21st century: Utilizing an innovative vacuum-assisted technology to safely expedite hair removal before surgery

BACKGROUND

Perioperative hair removal using clippers requires lengthy cleanup to remove loose hairs contaminating the operative field. We compared the amount of hair debris and associated microbiologic contamination produced during clipping of surgical sites using standard surgical clippers (SSC) or clippers fitted with a vacuum-assisted hair collection device (SCVAD).

METHODS

Trained nurses conducted bilateral hair clipping of the chest and groin of 18 male subjects using SSC or SCVAD. Before and during clipping, measurements of particulate matter and bacterial contamination were evaluated on settling plates placed next to each subject's chest and groin. Skin condition after clipping and total clipping/cleanup times were compared between SSC and SCVAD.

RESULTS

The microbial burden recovered from residual hair during cleanup in the SSC group was 3.9 log₁₀ CFU and 4.6 log₁₀ CFU from respective, chest, and groin areas. Use of the SCVAD resulted in a significant (P < .001) reduction in both residual hair and microbial contamination within the operative field compared with SSC.

CONCLUSIONS

Use of SCVAD resulted in significant (P < .001) reduction in total time required to clip and clean up residual hair contaminating the operative field compared with standard practice (ie, SSC), eliminating the need to physically remove dispersed hairs, which can harbor a significant microbial burden, from within the operative field.

Compliance of Perioperative Antibiotic Dosing and Surgical Site Infection Rate in Office-Based Elective Surgery

BACKGROUND

A best practice goal to reduce surgical site infection includes administration of antibiotics in the ideal preoperative window. This article evaluates an office surgical suite antibiotic administration rate and compares it with the timing of a local hospital treating a similar patient population. The hypothesis was that similar or better compliance and surgical site infection rates can be achieved in the office-based suite.

METHODS

A total of 277 office-based surgeries were analyzed for antibiotic administration time before incision and their corresponding surgical site infection rate.

RESULTS

Our facility administered timely prophylactic antibiotics in 96% of cases with a surgical site infection rate of 0.36%. This rate was significantly lower than a reported rate of 3.7%.

CONCLUSION

Low infection rates with high antibiotic administration rate suggest that compliance with best possible practice protocols is possible in the outpatient setting.

Negative pressure therapy is effective in abdominal incision closure

BACKGROUND

CDC wound classification demonstrates surgical site infection (SSI) occurs in 15%-30% of contaminated (class III) and >30% of dirty-infected (class IV) wounds. Several techniques have been used to decrease SSI rates in midline laparotomy incisions; however, no technique has shown superiority. Evidence suggests incisional negative pressure wound therapy (INPWT) can decrease wound complications, but no literature exists regarding INPWT for high-risk laparotomy incisions. We sought to analyze the efficacy of INPWT in the management of high-risk midline laparotomy incisions.

METHODS

Retrospective review of adult patients who underwent laparotomy between January 2013 and June 2014 with midline closure using INPWT. Only class III or IV wounds were included. Laparotomy incisions were loosely closed. INPWT set at 125 mm Hg is placed over oil emulsion impregnated gauze. INPWT is removed after 5 d and the wound left open to air. Records were reviewed for immediate and/or delayed surgical site complications. Primary end point was 30-d incisional SSI. Secondary end points included other surgical site complications.

RESULTS

One class III and 12 class IV wounds were treated with INPWT for a median of 5 d. The class III wound developed a small skin dehiscence with no evidence of superficial or deep SSI. Among class IV wounds, the rate of superficial and deep incisional SSI was 25% and 0%, respectively. The overall surgical site complication rate was 41.7%.

CONCLUSIONS

INPWT in closure of high-risk midline laparotomy incisions is a safe, effective method of wound closure with equivalent SSI rates to previously described methods.

Preadmission Application of 2% Chlorhexidine Gluconate (CHG): Enhancing Patient Compliance While Maximizing Skin Surface Concentrations

OBJECTIVE

Surgical site infections (SSIs) are responsible for significant morbidity and mortality. Preadmission skin antisepsis, while controversial, has gained acceptance as a strategy for reducing the risk of SSI. In this study, we analyze the benefit of an electronic alert system for enhancing compliance to preadmission application of 2% chlorhexidine gluconate (CHG).

DESIGN, SETTING, AND PARTICIPANTS

Following informed consent, 100 healthy volunteers in an academic, tertiary care medical center were randomized to 5 chlorhexidine gluconate (CHG) skin application groups: 1, 2, 3, 4, or 5 consecutive applications. Participants were further randomized into 2 subgroups: with or without electronic alert. Skin surface concentrations of CHG (μg/mL) were analyzed using a colorimetric assay at 5 separate anatomic sites.

INTERVENTION

Preadmission application of chlorhexidine gluconate, 2%

RESULTS

Mean composite skin surface CHG concentrations in volunteer participants receiving EA following 1, 2, 3, 4, and 5 applications were 1,040.5, 1,334.4, 1,278.2, 1,643.9, and 1,803.1 µg/mL, respectively, while composite skin surface concentrations in the no-EA group were 913.8, 1,240.0, 1,249.8, 1,194.4, and 1,364.2 µg/mL, respectively (ANOVA, P<.001). Composite ratios (CHG concentration/minimum inhibitory concentration required to inhibit the growth of 90% of organisms [MIC90]) for 1, 2, 3, 4, or 5 applications using the 2% CHG cloth were 208.1, 266.8, 255.6, 328.8, and 360.6, respectively, representing CHG skin concentrations effective against staphylococcal surgical pathogens. The use of an electronic alert system resulted in significant increase in skin concentrations of CHG in the 4- and 5-application groups (P<.04 and P<.007, respectively).

CONCLUSION

The findings of this study suggest an evidence-based standardized process that includes use of an Internet-based electronic alert system to improve patient compliance while maximizing skin surface concentrations effective against MRSA and other staphylococcal surgical pathogens.

Infect. Control Hosp. Epidemiol. 2016;37(3):254–259

Surgical site infection: poor compliance with guidelines and care bundles

Surgical site infections (SSIs) are probably the most preventable of the health care-associated infections. Despite the widespread international introduction of level I evidence-based guidelines for the prevention of SSIs, such as that of the National Institute for Clinical Excellence (NICE) in the UK and the surgical care improvement project (SCIP) of the USA, SSI rates have not measurably fallen. The care bundle approach is an accepted method of packaging best, evidence-based measures into routine care for all patients and, common to many guidelines for the prevention of SSI, includes methods for preoperative removal of hair (where appropriate), rational antibiotic prophylaxis, avoidance of perioperative hypothermia, management of perioperative blood glucose and effective skin preparation. Reasons for poor compliance with care bundles are not clear and have not matched the wide uptake and perceived benefit of the WHO 'Safe Surgery Saves Lives' checklist. Recommendations include the need for further research and continuous updating of guidelines; comprehensive surveillance, using validated definitions that facilitate benchmarking of anonymised surgeon-specific SSI rates; assurance that incorporation of checklists and care bundles has taken place; the development of effective communication strategies for all health care providers and those who commission services and comprehensive information for patients.

Central Venous Catheter Securement: Using the Healthcare and Technology Synergy Model to Take a Closer Look

Proper securement provides a safe vascular access device environment for both patients and health care providers. Successful securement protects central venous catheters from several sources of failure until the end of therapy by preventing central venous catheter movement during all phases of care. Movement causes vein trauma, bacterial migration, distal tip location variation, loss of dressing integrity, and even total dislodgement. Any of these events can have serious consequences, including catheter-related bloodstream infection, thrombosis, delay of treatment, catheter replacement, and potential hemorrhage, all of which can be life-threatening events, and increase costs. We review patient issues, practice issues, and the types of securement currently used in clinical settings.

The effect of Surgical Care Improvement Project measures on national trends on surgical site infections in open vascular procedures

OBJECTIVE

The Surgical Care Improvement Project (SCIP) is a national initiative to reduce surgical complications, including postoperative surgical site infection (SSI), through protocol-driven antibiotic usage. This study aimed to determine the effect SCIP guidelines have had on in-hospital SSIs after open vascular procedures.

METHODS

The Nationwide Inpatient Sample (NIS) was retrospectively analyzed using International Classification of Diseases, Ninth Revision, diagnosis codes to capture SSIs in hospital patients who underwent elective carotid endarterectomy, elective open repair of an abdominal aortic aneurysm (AAA), and peripheral bypass. The pre-SCIP era was defined as 2000 to 2005 and post-SCIP was defined as 2007 to 2010. The year 2006 was excluded because this was the transition year in which the SCIP guidelines were implemented. Analysis of variance and χ(2) testing were used for statistical analysis.

RESULTS

The rate of SSI in the pre-SCIP era was 2.2% compared with 2.3% for carotid endarterectomy (P = .06). For peripheral bypass, both in the pre- and post-SCIP era, infection rates were 0.1% (P = .22). For open, elective AAA, the rate of infection in the post-SCIP era increased significantly to 1.4% from 1.0% in the pre-SCIP era (P < .001). Demographics and in-hospital mortality did not differ significantly between the groups.

CONCLUSIONS

Implementation of SCIP guidelines has made no significant effect on the incidence of in-hospital SSIs in open vascular operations; rather, an increase in SSI rates in open AAA repairs was observed. Patient-centered, bundled approaches to care, rather than current SCIP practices, may further decrease SSI rates in vascular patients undergoing open procedures.

What is the quality of reporting of studies of interventions to increase compliance with antibiotic prophylaxis?

BACKGROUND

Despite studies reporting successful interventions to increase antibiotic prophylaxis compliance, surgical site infections remain a significant problem. The reasons for this lack of improvement are unknown. This review evaluates the internal and external validity of quality improvement studies of interventions to increase surgical antibiotic prophylaxis compliance.

STUDY DESIGN

Three investigators independently performed systematic literature searches and selected eligible studies that evaluated interventions to improve perioperative antibiotic prophylaxis timing, type, and/or discontinuation. Studies published before the Surgical Infection Prevention project inception in 2002 were excluded. Each study was assessed based on modified criteria for evaluating quality improvement studies (Standards for Quality Improvement Reporting Excellence) and for facilitating implementation of evidence into practice (Reach-Efficacy-Adoption-Implementation-Maintenance).

RESULTS

Forty-six articles met inclusion criteria; 93% reported improvement in antibiotic prophylaxis compliance. Surgical site infections were evaluated in 50% of studies and 65% reported an improvement. Less than 5% of studies used randomization, allocation concealment, or blinding. Nine percent of studies described efforts to minimize bias in the design results and analysis and 13% described a sample size calculation. Approximately one-third of studies described participant adoption of the intervention (26%), factors affecting generalizability (33%), or implementation barriers (37%). Most studies (80%) used multiple interventions; no single intervention was associated with change in compliance. Studies with the lowest baseline compliance showed the greatest improvement, regardless of the intervention(s).

CONCLUSIONS

The methodology and reporting of quality improvement studies on perioperative antibiotic prophylaxis is suboptimal, and factors that would improve generalizability of successful intervention implementation are infrequently reported. Clinicians should use caution in applying the results of these studies to their general practice.

Is there an evidence-based argument for embracing an antimicrobial (triclosan)-coated suture technology to reduce the risk for surgical-site infections?: A meta-analysis

BACKGROUND

It has been estimated that 750,000 to 1 million surgical-site infections (SSIs) occur in the United States each year, causing substantial morbidity and mortality. Triclosan-coated sutures were developed as an adjunctive strategy for SSI risk reduction, but a recently published systematic literature review and meta-analysis suggested that no clinical benefit is associated with this technology. However, that study was hampered by poor selection of available randomized controlled trials (RCTs) and low patient numbers. The current systematic review involves 13 randomized, international RCTs, totaling 3,568 surgical patients.

METHODS

A systematic literature search was performed on PubMed, Embase/Medline, Cochrane database group (Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Health Economic Evaluations Database/Database of Health Technology Assessments), and www.clinicaltrials.gov to identify RCTs of triclosan-coated sutures compared with conventional sutures and assessing the clinical effectiveness of antimicrobial sutures to decrease the risk for SSIs. A fixed- and random-effects model was developed, and pooled estimates reported as risk ratio (RR) with a corresponding 95% confidence interval (CI). Publication bias was assessed by analyzing a funnel plot of individual studies and testing the Egger regression intercept.

RESULTS

The meta-analysis (13 RCTs, 3,568 patients) found that use of triclosan antimicrobial-coated sutures was associated with a decrease in SSIs in selected patient populations (fixed effect: RR = 0.734; 95% CI: 0.590-0.913; P = .005; random-effect: RR = 0.693; 95% CI: 0.533-0.920; P = .011). No publication bias was detected (Egger intercept test: P = .145).

CONCLUSION

Decreasing the risk for SSIs requires a multifaceted "care bundle" approach, and this meta-analysis of current, pooled, peer-reviewed, randomized controlled trials suggests a clinical effectiveness of antimicrobial-coated sutures (triclosan) in the prevention of SSIs, representing Center for Evidence-Based Medicine level 1a evidence.

Surgical care improvement project (SCIP): has its mission succeeded?

The purpose of this study was to determine if adherence to the surgical care improvement project (SCIP) measures could further reduce rate of surgical site infection (SSI) and venous thromboembolism (VTE) in total joint arthroplasty (TJA) patients. We retrospectively identified all patients who underwent primary or revision TJA at our institution between July 2000 and June 2009. After implementation of SCIP measures, rate of superficial SSI increased (0.42% versus 0.60%, P=0.05) while rate of deep SSI decreased from 0.92% to 0.82% (P=0.46). The rate of DVT was 0.92% before and 0.83% after implementation of SCIP (P=0.51); however, rate of PE increased from 0.87% to 1.30% (P=0.002). Our findings indicated that SCIP has not been successful in reducing complications in TJA patients.

Appropriateness of surgical antimicrobial prophylaxis in the Latium region of Italy, 2008: a multicenter study

BACKGROUND

There is still wide variability in surgical antimicrobial prophylaxis (SAP) practice by different surgical teams and specialties, with potential impact on adverse events and the emergence of antibiotic resistance.

METHODS

We assessed SAP appropriateness in a regional prospective multicenter study on the basis of the agreement of the Surgical Care Improvement Project indicators (SCIP-Inf) with Italian guidelines (GL).

RESULTS

Prophylaxis was administered in 2,664 of 2,835 procedures (94%): In 2,346 of 2,468 (95%) as indicated and in 318 of 367 (86.6%) in which they were not indicated. The SCIP-Inf1 (timing), SCIP-Inf2 (antibiotic choice), and SCIP-Inf3 (duration) were in agreement with GL in 1,172 (50%), 1,983 (84.5%), and 1,121 (48%) of 2,346 procedures, respectively.

CONCLUSIONS

These results suggest the need for implementation of an antimicrobial stewardship program in this surgical setting.

Microbiology of explanted suture segments from infected and noninfected surgical patients

Sutures under selective host/environmental factors can potentiate postoperative surgical site infection (SSI). The present investigation characterized microbial recovery and biofilm formation from explanted absorbable (AB) and nonabsorbable (NAB) sutures from infected and noninfected sites. AB and NAB sutures were harvested from noninfected (70.9%) and infected (29.1%) sites in 158 patients. At explantation, devices were sonicated and processed for qualitative/quantitative bacteriology; selective sutures were processed for scanning electron microscopy (SEM). Bacteria were recovered from 85 (53.8%) explanted sites; 39 sites were noninfected, and 46 were infected. Suture recovery ranged from 11.1 to 574.6 days postinsertion. A significant difference in mean microbial recovery between noninfected (1.2 isolates) and infected (2.7 isolates) devices (P < 0.05) was noted. Staphylococcus epidermidis, Staphylococcus aureus, coagulase-negative staphylococci (CNS), Peptostreptococcus spp., Bacteroides fragilis, Escherichia coli, Enterococcus spp., Pseudomonas aeruginosa, and Serratia spp. were recovered from infected devices, while commensal skin flora was recovered from noninfected devices. No significant difference in quantitative microbial recovery between infected monofilament and multifilament sutures was noted. Biofilm was present in 100% and 66.6% of infected and noninfected devices, respectively (P < 0.042). We conclude that both monofilament and braided sutures provide a hospitable surface for microbial adherence: (i) a significant difference in microbial recovery from infected and noninfected sutures was noted, (ii) infected sutures harbored a mixed flora, including multidrug-resistant health care-associated pathogens, and (iii) a significant difference in the presence or absence of a biofilm in infected versus noninfected explanted devices was noted. Further studies to document the benefit of focused risk reduction strategies to minimize suture contamination and biofilm formation postimplantation are warranted.

Surgical care improvement project in the value-based purchasing era: more harm than good?

The Surgical Care Improvement Project (SCIP) started in 2006 as a core measure to reduce perioperative morbidity and mortality, with many measures addressing perioperative antibiotic usage and timing. However, measures are often rolled out without consideration of their full impact, causing confusion, frustration, and possibly patient harm. We have provided examples of each. The institution of SCIP has markedly increased the compliance to its measures but little evidence shows that it provides any substantial benefit to patients, whereas this improved compliance comes at the cost of significant time, money, and staff resources. Despite this, several SCIP measures, which are currently incorporated into quality contracts, will be tied to Medicare reimbursement in 2013 under value-based purchasing, with third-party payers likely following suit. This may lead to inappropriate lower compensation of hospitals providing good care with questionable effects on patient outcomes.

Patient safety in the critical care environment

Improving the quality and safety of intensive care unit (ICU) care in the United States is a significant challenge for the future. Obtaining improvement in systems of care is difficult given the reactionary mode physicians tend to enter when dealing with moment-to-moment crises. It will be important to implement quality and safety measures that are already supported by evidence. Improvement of device safety will be critical to reducing the large number of device-related complications that occur in US ICUs. Prospective collection of adverse events with rigorous analysis will be important to allow systematic errors to be exposed and corrected.

Adherence to surgical care improvement project measures and post-operative surgical site infections

BACKGROUND

Surgical site infection (SSI) is unequivocally morbid and costly. The estimated 300,000 SSIs annually in the United States represent the second most common infection among surgical patients, prolong hospitalization by 7-10 days, and have an estimated annual incremental cost of $1 billion. The mortality rate associated with SSI is 3%, with about three quarters of deaths being attributable directly to the infection. Prevention is possible for the most part, and concerted effort has been made to limit these infections, arguably to little effect.

METHODS

Review of pertinent English-language literature.

RESULTS

Numerous risk factors for SSI and tactics for prevention have been described, but efforts to bundle these tactics into an effective, comprehensive prevention program have been disappointing. Numerous studies now demonstrate that the Surgical Care Improvement Program (SCIP), which focused on process improvement rather than outcomes, has been ineffective despite governmental support, financial penalties for non-compliance, and consequent widespread implementation.

CONCLUSION

Required reporting has increased awareness of the problem of SSI, but just as the complexity of SSI risk, pathogenesis, and preventions reflects the complexity of the disease, many other factors must be taken into account, including the skill and knowledge of the surgical team and promulgation of a culture of quality and safety in surgical patient care.