Proportion of Surgical Site Infections Occurring after Hospital Discharge: A Systematic Review

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perioperative Antibiotic Prophylaxis

BACKGROUND

Postoperative surgical site infections (SSI) account for almost 25% of all nosocomial infections in Germany and are a source of increased morbidity and mortality.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and on national and international guidelines.

RESULTS

The individual risk factors for SSI must be assessed before any surgical procedure. A body-mass index above 30 kg/m2 is associated with an unadjusted risk ratio of 1.35 [1.28; 1.41] for SSI, which rises to 3.29 [2.99; 3.62] if the patient is also immunosuppressed. The risk of SSI is also significantly higher with certain types of procedure. Perioperative antibiotic prophylaxis (PAP) is clearly indicated for operations that carry a high risk of SSI (e.g., colorectal surgery) and for those that involve the implantation of alloplastic material (e.g., hip endoprostheses). PAP can usually be administered with basic antibiotics such as cefazoline. The basic principles of PAP are that it should be given by the anesthesia team in the interval from 60 minutes preoperatively up to shortly before the incision, and that its administration should only be for a short period of time, usually as a single shot. Continuing PAP onward into the postoperative period leads to increased toxicity, bacterial superinfections, and antibiotic resistance.

CONCLUSION

The evidence shows that perioperative antibiotic prophylaxis is a component of a bundle of measures that can help prevent SSI. Strict indications and adherence to the basic principles of PAP are essential for therapeutic success.

Telemedicine for sustainable postoperative follow-up: a prospective pilot study evaluating the hybrid life-cycle assessment approach to carbon footprint analysis

Introduction

Surgical site infections (SSI) are the most common healthcare-associated infections; however, access to healthcare services, lack of patient awareness of signs, and inadequate wound surveillance can limit timely diagnosis. Telemedicine as a method for remote postoperative follow-up has been shown to improve healthcare efficiency without compromising clinical outcomes. Furthermore, telemedicine would reduce the carbon footprint of the National Health Service (NHS) through minimising patient travel, a significant contributor of carbon dioxide equivalent (CO2e) emissions. Adopting innovative approaches, such as telemedicine, could aid in the NHS Net-Zero target by 2045. This study aimed to provide a comprehensive analysis of the feasibility and sustainability of telemedicine postoperative follow-up for remote diagnosis of SSI.

Methods

Patients who underwent a lower limb vascular procedure were reviewed remotely at 30 days following the surgery, with a combined outcome measure (photographs and Bluebelle Wound Healing Questionnaire). A hybrid life-cycle assessment approach to carbon footprint analysis was used. The kilograms of carbon dioxide equivalent (kgCO2e) associated with remote methods were mapped prospectively. A simple outpatient clinic review, i.e., no further investigations or management required, was modelled for comparison. The Department of Environment, Food, and Rural Affairs (DEFRA) conversion factors plus healthcare specific sources were used to ascertain kgCO2e. Patient postcodes were applied to conversion factors based upon mode of travel to calculate kgCO2e for patient travel. Total and median (interquartile range) carbon emissions saved were presented for both patients with and without SSI.

Results

Altogether 31 patients (M:F 2.4, ±11.7 years) were included. The median return distance for patient travel was 42.5 (7.2-58.7) km. Median reduction in emissions using remote follow-up was 41.2 (24.5-80.3) kgCO2e per patient (P < 0.001). The carbon offsetting value of remote follow-up is planting one tree for every 6.9 patients. Total carbon footprint of face-to-face follow-up was 2,895.3 kgCO2e, compared with 1,301.3 kgCO2e when using a remote-first approach (P < 0.001). Carbon emissions due to participants without SSI were 700.2 kgCO2e by the clinical method and 28.8 kgCO2e from the remote follow-up.

Discussion

This model shows that the hybrid life-cycle assessment approach is achievable and reproducible. Implementation of an asynchronous digital follow-up model is effective in substantially reducing the carbon footprint of a tertiary vascular surgical centre. Further work is needed to corroborate these findings on a larger scale, quantify the impact of telemedicine on patient's quality of life, and incorporate kgCO2e into the cost analysis of potential SSI monitoring strategies.

Digital tools for post-discharge surveillance of surgical site infection

AIMS

Conduct a scoping review on the development and use of digital tools for post-discharge surgical site infection surveillance.

DESIGN

Scoping review.

DATA SOURCES

Science Direct, PubMed, Embase, Literatura Latino-Americana e do Caribe em Ciências da Saúde and Cumulative Index to Nursing and Allied Health Literature were searched from 2013 to May 2022. Six intellectual property registries were reviewed from 2013 to 2022.

REVIEW METHODS

The review followed the Joanna Briggs Institute model, and included intellectual property records (applications, prototypes and software) and scientific articles published in any language on the development and/or testing of digital tools for post-discharge surveillance of surgical site infection among surgical patients aged 18 and over.

RESULTS

One intellectual property record and 13 scientific articles were identified, covering 10 digital tools. The intellectual property record was developed and registered by a China educational institution in 2018. The majority of manuscripts were prospective cohort studies and randomized clinical trials, published between 2016 and 2022, and more than half were conducted in the United States. The population included adult patients undergoing cardiac, thoracic, vascular, abdominal, arthroplasty and caesarean surgery. The main functionalities of the digital tools were the previously prepared questionnaire, the attachment of a wound image, the integrated Web system and the evaluation of data by the health team, with post-discharge surgical site infection surveillance time between 14 and 30 days after surgery.

CONCLUSION

Digital tools show promise for the surveillance of surgical site infection, collaborating with the early detection of wound infection.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Mobile technology was favourable for detecting surgical site infections, reducing unnecessary visits to the health service, and increasing patient satisfaction.

IMPACT

Technological advances in the health area open new perspectives for post-discharge surveillance of surgical site infection. WHAT IS ALREADY KNOWN?: There is underreporting of surgical site infections due to difficulties related to traditional methods of post-discharge surveillance. The use of digital tools within surgical site infection surveillance is increasing. Benefits of using digital tools within surgical site infection surveillance have been reported. WHAT HAS THIS STUDY ADDED TO OUR KNOWLEDGE?: This scoping review is one of the first to analyse the development and use of digital tools for post-discharge surveillance of surgical site infection in different countries. The main functionalities of digital tools are: structured questionnaires; attachment of wound images; integrated web systems; and evaluation of data by professionals. The use of mobile technology is favourable for detecting surgical site infections with a reduction in costs from face-to-face consultations and increased patient satisfaction. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: Healthcare providers can successfully use digital tools for surgical site infection post-discharge surveillance. Remote monitoring can reduce unnecessary patient visits to healthcare facilities. Policy makers can study how to implement digital platforms for remote patient monitoring.

REPORTING METHOD

PRISMA statement for Scoping Reviews (PRISMA-ScR).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

TRIAL AND PROTOCOL REGISTRATION

The study protocol was registered in the OSF (https://doi.org/10.17605/OSF.IO/BA8D6).

Medical Device-Associated Healthcare Infections: Sterilization and the Potential of Novel Biological Approaches to Ensure Patient Safety

Healthcare-associated infections caused by multi-drug-resistant pathogens are increasing globally, and current antimicrobial options have limited efficacy against these robust species. The WHO details the critically important bacterial and fungal species that are often associated with medical device HAIs. The effective sterilization of medical devices plays a key role in preventing infectious disease morbidity and mortality. A lack of adherence to protocol and limitations associated with each sterilization modality, however, allows for the incidence of disease. Furthermore, issues relating to carcinogenic emissions from ethylene oxide gas (EtO) have motivated the EPA to propose limiting EtO use or seeking alternative sterilization methods for medical devices. The Food and Drug Administration supports the sterilization of healthcare products using low-temperature VH2O2 as an alternative to EtO. With advances in biomaterial and medical devices and the increasing use of combination products, current sterilization modalities are becoming limited. Novel approaches to disinfection and sterilization of medical devices, biomaterials, and therapeutics are warranted to safeguard public health. Bacteriophages, endolysins, and antimicrobial peptides are considered promising options for the prophylactic and meta-phylactic control of infectious diseases. This timely review discusses the application of these biologics as antimicrobial agents against critically important WHO pathogens, including ESKAPE bacterial species.

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.

Prognostic models for surgical-site infection in gastrointestinal surgery: systematic review

BACKGROUND

Identification of patients at high risk of surgical-site infection may allow clinicians to target interventions and monitoring to minimize associated morbidity. The aim of this systematic review was to identify and evaluate prognostic tools for the prediction of surgical-site infection in gastrointestinal surgery.

METHODS

This systematic review sought to identify original studies describing the development and validation of prognostic models for 30-day SSI after gastrointestinal surgery (PROSPERO: CRD42022311019). MEDLINE, Embase, Global Health, and IEEE Xplore were searched from 1 January 2000 to 24 February 2022. Studies were excluded if prognostic models included postoperative parameters or were procedure specific. A narrative synthesis was performed, with sample-size sufficiency, discriminative ability (area under the receiver operating characteristic curve), and prognostic accuracy compared.

RESULTS

Of 2249 records reviewed, 23 eligible prognostic models were identified. A total of 13 (57 per cent) reported no internal validation and only 4 (17 per cent) had undergone external validation. Most identified operative contamination (57 per cent, 13 of 23) and duration (52 per cent, 12 of 23) as important predictors; however, there remained substantial heterogeneity in other predictors identified (range 2-28). All models demonstrated a high risk of bias due to the analytic approach, with overall low applicability to an undifferentiated gastrointestinal surgical population. Model discrimination was reported in most studies (83 per cent, 19 of 23); however, calibration (22 per cent, 5 of 23) and prognostic accuracy (17 per cent, 4 of 23) were infrequently assessed. Of externally validated models (of which there were four), none displayed 'good' discrimination (area under the receiver operating characteristic curve greater than or equal to 0.7).

CONCLUSION

The risk of surgical-site infection after gastrointestinal surgery is insufficiently described by existing risk-prediction tools, which are not suitable for routine use. Novel risk-stratification tools are required to target perioperative interventions and mitigate modifiable risk factors.

[Deep Learning-Based Identification of Common Complication Features of Surgical Incisions]

Objective

In recent years, due to the development of accelerated recovery after surgery and day surgery in the field of surgery, the average length-of-stay of patients has been shortened and patients stay at home for post-surgical recovery and healing of the surgical incisions. In order to identify, in a timely manner, the problems that may appear at the incision site and help patients prevent or reduce the anxiety they may experience after discharge, we used deep learning method in this study to classify the features of common complications of surgical incisions, hoping to realize patient-directed early identification of complications common to surgical incisions.

Methods

A total of 1 224 postoperative photographs of patients' surgical incisions were taken and collected at a tertiary-care hospital between June 2021 and March 2022. The photographs were collated and categorized according to different features of complications of the surgical incisions. Then, the photographs were divided into training, validation, and test sets at the ratio of 8∶1∶1 and 4 types of convolutional neural networks were applied in the training and testing of the models.

Results

Through the training of multiple convolutional neural networks and the testing of the model performance on the basis of a test set of 300 surgical incision images, the average accuracy of the four ResNet classification network models, SE-ResNet101, ResNet50, ResNet101, and SE-ResNet50, for surgical incision classification was 0.941, 0.903, 0.896, and 0.918, respectively, the precision was 0.939, 0.898, 0.868, and 0.903, respectively, and the recall rate was 0.930, 0.880, 0.850, and 0.894, respectively, with the SE-Resnet101 network model showing the highest average accuracy of 0.941 for incision feature classification.

Conclusion

Through the combined use of deep learning technology and images of surgical incisions, problematic features of surgical incisions can be effectively identified by examining surgical incision images. It is expected that patients will eventually be able to perform self-examination of surgical incisions on smart terminals.

Inter-rater agreement of CDC criteria and ASEPSIS score in assessing surgical site infections after cesarean section: a prospective observational study

Objective

To assess and compare the inter-rater agreement of the CDC criteria and the ASEPSIS score in identifying surgical site infections after cesarean section.

Methods

Prospective observational study including 110 patients subjected to a cesarean section at our institution. Surgical wounds were managed according to standard care and were photographed on the third, seventh, and thirtieth postoperative day or during any evaluation in case of complications. Three expert surgeons reviewed the prospectively gathered data and photographs and classified each wound using CDC criteria and the ASEPSIS score. The inter-rater agreements of CDC criteria and ASEPSIS score were determined with Krippendorff's Alpha with linear weights and compared with a confidence interval approach.

Results

The weighted α coefficient for CDC criteria was 0.587 (95%CI, 0.411-0.763, p < 0.001, "moderate" agreement according to Altman's interpretation of weighted agreement coefficient), while the weighted α coefficient for the ASEPSIS score was 0.856 (95%CI, 0.733-0.980, p < 0.001, "very good" agreement).

Conclusion

ASEPSIS score presents a "very good" inter-rater agreement for surgical site infections identification after cesarean, resulting in a more objective method than CDC criteria ("moderate" inter-rater agreement). ASEPSIS score could represent an objective tool for managing and monitoring surgical site infections after cesarean section, also by photographic evaluation.

[allergy to penicillin - no beta-lactam antibiotics?]

Drug allergies are frequently reported by patients undergoing pre-anesthesia evaluation, potentially resulting in a suboptimal treatment with alternative substances. While about 10% of patients report to be allergic to penicillin, less than 1% have a true IgE-mediated allergy. Multiple factors contribute to this large prevalence, such as misinterpretations of common gastrointestinal side effects as “allergic”, a history of penicillin treatment for infectious mononucleosis resulting in skin rashes, uncritical acceptance of the diagnosis by medical staff or neglect to the fact that most patients will lose their sensitivity after 10 years. In addition to this, cephalosporins are regularly withheld from patients with penicillin allergy due to an unwarranted fear of cross-reactivity. Therefore, a correct identification of those in which penicillins or cephalosporins are truly contraindicated is paramount to avoid an unnecessary use of antibiotics with a less favorable spectrum.

Unexpected Benefits of Coronavirus Disease 2019: Impact of Coronavirus Disease 2019 Pandemic on Surgical Site Infection: A Systematic Review and Meta-Analysis

Background: We aimed to summarize and synthesize the current evidence regarding the indirect impact of the coronavirus disease 2019 (COVID-19) pandemic and its associated measures on the surgical site infection (SSI) rate compared with the pre-pandemic period. Methods: A computerized search was conducted on MEDLINE via PubMed, Web of Science, and Scopus using the relevant keywords. Two-stage screening and data extraction were done. The National Institutes of Health (NIH) tools were used for the quality assessment. The Review Manager 5.4.1 program was used for the analysis. Results: Sixteen articles (n = 157,426 patients) were included. The COVID-19 pandemic and lockdown were associated with reduced risk of SSIs after surgery (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.56-0.75; p < 0.00001) and (OR, 0.49; 95% CI, 0.29-0.84; p = 0.009), respectively. There was no significant reduction in the SSIs rate after applying the extended use of masks (OR, 0.73; 95% CI, 0.30-1.73; p = 0.47). A reduction in the superficial SSI rate during the COVID-19 pandemic compared with the pre-COVID-19 pandemic period was observed (OR, 0.58; 95% CI, 0.45-0.75; p < 0.0001). Conclusions: The current evidence suggests that the COVID-19 pandemic may have some unexpected benefits, including improved infection control protocols, which resulted in reduced SSI rates, especially superficial SSIs. In contrast to extended mask use, the lockdown was associated with reduced rates of SSIs.

Image-based digital post-discharge surveillance in England: measuring patient enrolment, engagement, clinician response times, surgical site infection, and carbon footprint

BACKGROUND

Surgical site infections (SSIs) can have a significant impact on patients, their families and healthcare providers. With shortening inpatient periods, the post-discharge element of surveillance is becoming increasingly important. Proactive surveillance, including digital wound images using patient smartphones, may be an efficient alternative to traditional methods for collecting post-discharge surveillance (PDS).

AIM

To determine success in patient enrolment and engagement including reasons for non-response, the time for clinicians to respond to patients, SSI rates, and carbon emissions when conducting PDS using patient smartphones.

METHODS

An evaluation was undertaken for a one-month period (June 2022) in two adult cardiac surgery services which routinely used patient smartphones for PDS, using the secure Islacare (Isla) system.

FINDINGS

The initial patient response rate for Isla was 87.3%, and the majority of patients (73%) remained engaged throughout the 30-day period. There was no significant difference in age, gender, operation type or distance to hospital between Isla responders or non-responders, or if the hospital provided a photo at discharge or not. Patients using Isla had a shorter post-discharge stay (P = 0.03), although this was not attributed to the platform. Patients not owning a smartphone and a technical issue were the main barriers to participation. Overall, nine SSIs were recorded, eight through the Isla surveillance and one through a hospital transfer readmission. The carbon emission associated with the SSI ranged from 5 to 2615 kg CO2e.

CONCLUSION

In a real-world setting, using patient smartphones is an effective method to collect PDS, including wound images.

Remote assessment of surgical site infection (SSI) using patient-taken wound images: Development and evaluation of a method for research and routine practice

BACKGROUND/AIM

Clinical assessment of wounds for surgical site infection (SSI) after hospital discharge is challenging and resource intensive. Remote assessment using digital images may be feasible and expedite SSI diagnosis. Acceptable and accurate methods for this process are needed. This study developed and evaluated the feasibility, acceptability and usability of a method for patients to capture standardised wound images for remote wound assessment to detect SSI.

MATERIALS AND METHODS

The work was conducted in two phases. Phase I involved: i) a review of literature to identify key components of photography relevant to taking wound images, ii) development of wound photography instructions for patients and a secure process for transmission of images using electronic survey software and iii) pre-testing of the photography instructions and processing method with a sample of 16 patients using cognitive interviews and observations. Phase II involved a prospective cohort study of 89 patients to evaluate the feasibility, acceptability and usability of the remote method following discharge from hospital after surgery. Quality of the images was assessed by three independent clinical reviewers.

RESULTS

Some 21 key components for photographing wounds were identified from 11 documents. Of these, 16 were relevant to include in instructions for patients to photograph their wounds. Pre-testing and subsequent iterations improved understanding and ease of use of the instructions and the process for transmitting images. Fifty-two of 89 (58.4%) patients testing the method remotely took an image of their wound(s) and 46/52 (88.5%) successfully transmitted images. When it was possible to ascertain a reason for not taking/transmitting images, this was primarily health problems (n = 7) or lack of time/poor engagement with the study (n = 4) rather than problems relating to technology/competency (n = 2) or practical issues relating to the wound itself (n = 2). Eighty-seven (85.3%) of the 102 images received were evaluated to be of high quality and sufficient to remotely assess SSI by at least two independent reviewers.

CONCLUSION

A simple, standardised and acceptable method for patients to take and transmit wound images suitable for remote assessment of SSI has been developed and tested and is now available for use in routine clinical care and research.

The detection and prediction of surgical site infections using multi-modal sensors and machine learning: Results in an animal model

Introduction

Surgical Site Infection (SSI) is a common healthcare-associated infection that imposes a considerable clinical and economic burden on healthcare systems. Advances in wearable sensors and digital technologies have unlocked the potential for the early detection and diagnosis of SSI, which can help reduce this healthcare burden and lower SSI-associated mortality rates.

Methods

In this study, we evaluated the ability of a multi-modal bio-signal system to predict current and developing superficial incisional infection in a porcine model infected with Methicillin Susceptible Staphylococcus Aureus (MSSA) using a bagged, stacked, and balanced ensemble logistic regression machine learning model.

Results

Results demonstrated that the expression levels of individual biomarkers (i.e., peri-wound tissue oxygen saturation, temperature, and bioimpedance) differed between non-infected and infected wounds across the study period, with cross-correlation analysis indicating that a change in bio-signal expression occurred 24 to 31 hours before this change was reflected by clinical wound scoring methods employed by trained veterinarians. Moreover, the multi-modal ensemble model indicated acceptable discriminability to detect the presence of a current superficial incisional SSI (AUC = 0.77), to predict an SSI 24 hours in advance of veterinarian-based SSI diagnosis (AUC = 0.80), and to predict an SSI 48 hours in advance of veterinarian-based SSI diagnosis (AUC = 0.74).

Discussion

In sum, the results of the current study indicate that non-invasive multi-modal sensor and signal analysis systems have the potential to detect and predict superficial incisional SSIs in porcine subjects under experimental conditions.

Clinical and economic burden of surgical site infections in inpatient care in Germany: A retrospective, cross-sectional analysis from 79 hospitals

BACKGROUND

Surgical site infections (SSI) present a substantial burden to patients and healthcare systems. This study aimed to elucidate the prevalence of SSIs in German hospitals and to quantify their clinical and economic burden based on German hospital reimbursement data (G-DRG).

METHODS

This retrospective, cross-sectional study used a 2010-2016 G-DRG dataset to determine the prevalence of SSIs in hospital, using ICD-10-GM codes, after surgical procedures. The captured economic and clinical outcomes were used to quantify and compare resource use, reimbursement and clinical parameters for patients who had or did not have an SSI.

FINDINGS

Of the 4,830,083 patients from 79 hospitals, 221,113 were eligible. The overall SSI prevalence for the study period was 4.9%. After propensity-score matching, procedure type, immunosuppression and BMI ≥30 were found to significantly affect the risk of SSI (p<0.001). Mortality and length of stay (LOS) were significantly higher in patients who had an SSI (mortality: 9.3% compared with 4.5% [p<0.001]; LOS (median [interquartile range, IQR]): 28 [27] days compared with 12 [8] days [p<0.001]). Case costs were significantly higher for the SSI group (median [IQR]) €19,008 [25,162] compared with € 9,040 [7,376] [p<0.001]). A median underfunding of SSI was identified at €1,534 per patient.

INTERPRETATION

The dataset offers robust information about the "real-world" clinical and economic burden of SSI in hospitals in Germany. The significantly increased mortality of patients with SSI, and their underfunding, calls for a maximization of efforts to prevent SSI through the use of evidence-based SSI-reduction care bundles.

The diagnostic test accuracy of telemedicine for detection of surgical site infection: A systematic review protocol

Since the COVID-19 pandemic there has been a rapid uptake and utilisation of telemedicine in all aspects of healthcare. This presents a key opportunity in surgical site infection surveillance. Remote follow up methods have been used via telephone, with photographs and questionnaires for post-operative reviews with varying results. This review therefore aims to comprehensively synthesise available evidence for the diagnostic accuracy of all forms of SSI telemedicine monitoring. The protocol has been established as per both PRISMA-P (S1 Table) and the Cochrane handbook for reviews of diagnostic test accuracy. Medline, Embase, CENTRAL and CINAHL will be searched using a complete search strategy developed with librarian input, in addition to google scholar and hand searching. All study designs with patients over 18 and undergone a primarily closed surgical procedure will be eligible. Index tests will include all forms of telemedicine and a subgroup analysis performed for each of these. Comparative tests must include face to face review, and all reference standards will be included again for sub-group analyses. Search results will be screened by two investigators independently with a third providing consensus review on disagreements. Methodological quality will be assessed using the QUADAS-2 tool, first validated by two investigators as per the Cochrane handbook. Exploratory analysis will formulate summary receiver operating characteristic curves and forest plots with estimates of sensitivity and specificity of the included studies. Sources of heterogeneity will be identifying and investigated through further analysis. Potential benefits of telemedicine integration in surgical practice will reduce cost and travel time to patients in addition to avoiding wasted clinic appointments, important considerations in a peri-pandemic era. To avoid missed or further complications, there must be confidence in the ability to diagnose infection. This review will systematically determine whether telemedicine is accurate for surgical site infection diagnosis, which methods are well established and if further research is indicated.

Risk Factors for Post-cardiac Surgery Infections

Background Cardiac surgery infection is a life-threatening complication associated with high morbidity and mortality. One of the main types of these infections, surgical site infections (SSIs), also called postoperative wound infections basically delayed the post-surgical recovery in many patients. These infections rarely happen within 30 days after surgery due to different risk factors. Objectives The purpose of this study is to determine the risk factors that are involved in causing post-cardiac surgical infections. Methods This study was a retrospective study. The data of postoperative cardiac patients was obtained from the Cardiology and Cardiac Surgery Center in King Fahad Armed Force Hospital, Jeddah. Data on the patients were collected from 2016 to 2021. Eligible patients were those of age 18 and greater. These patients were evaluated on basis of the pre and postoperative risk factors and were analyzed for 30 days after discharge and those that developed SSIs were identified. Results Out of the total number of 2366 patients, 151 patients (6.4%) were identified with post-surgery infections out of which 107 (4.5%) had developed superficial wound infections (SSWIs) and 44 (1.9%) had developed deep wound infections (DSWIs). Infection mainly occurs in the male population (n=88, 58.3%). Major risk factors that were the main cause of post-cardiac surgery infections were diabetes (61.5%), hypertension (56.9%), smoking (38.4%), renal failure (27.1%), and re-do operation (25.1%). Conclusion Our study has demonstrated major risk factors that are involved in the occurrence of post-cardiac surgery infections like smoking, diabetes mellitus, sex, more than one operation during a single stay, etc. In the future, the contribution of various other factors involved in the occurrence of surgical site infections and best practices and methods should be studied and implemented to prevent the occurrence of post-cardiac surgery infections. Various simple techniques can still be utilized to prevent these sorts of infections, which will decrease the mortality rate.

Diagnostic accuracy of telemedicine for detection of surgical site infection: a systematic review and meta-analysis

The Sars-CoV-2 pandemic catalysed integration of telemedicine worldwide. This systematic review assesses it’s accuracy for diagnosis of Surgical Site Infection (SSI). Databases were searched for telemedicine and wound infection studies. All types of studies were included, only paired designs were taken to meta-analysis. QUADAS-2 assessed methodological quality. 1400 titles and abstracts were screened, 61 full text reports were assessed for eligibility and 17 studies were included in meta-analysis, mean age was 47.1 ± 13.3 years. Summary sensitivity and specificity was 87.8% (95% CI, 68.4–96.1) and 96.8% (95% CI 93.5–98.4) respectively. The overall SSI rate was 5.6%. Photograph methods had lower sensitivity and specificity at 63.9% (95% CI 30.4–87.8) and 92.6% (95% CI, 89.9–94.5). Telemedicine is highly specific for SSI diagnosis is highly specific, giving rise to great potential for utilisation excluding SSI. Further work is needed to investigate feasibility telemedicine in the elderly population group.

mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda

Background

Surgical site infections (SSIs) cause a significant global public health burden in low and middle-income countries. Most SSIs develop after patient discharge and may go undetected. We assessed the feasibility and diagnostic accuracy of an mHealth-community health worker (CHW) home-based telemedicine intervention to diagnose SSIs in women who delivered via caesarean section in rural Rwanda.

Methods

This prospective cohort study included women who underwent a caesarean section at Kirehe District Hospital between September 2019 and March 2020. At postoperative day 10 (±3 days), a trained CHW visited the woman at home, provided wound care and transmitted a photo of the wound to a remote general practitioner (GP) via WhatsApp. The GP reviewed the photo and made an SSI diagnosis. The next day, the woman returned to the hospital for physical examination by an independent GP, whose SSI diagnosis was considered the gold standard for our analysis. We describe the intervention process indicators and report the sensitivity and specificity of the telemedicine-based diagnosis.

Results

Of 787 women included in the study, 91.4% (n=719) were located at their home by the CHW and all of them (n=719, 100%) accepted the intervention. The full intervention was completed, including receipt of GP telemedicine diagnosis within 1 hour, for 79.0% (n=623). The GPs diagnosed 30 SSIs (4.2%) through telemedicine and 38 SSIs (5.4%) through physical examination. The telemedicine sensitivity was 36.8% and specificity was 97.6%. The negative predictive value was 96.4%.

Conclusions

Implementation of an mHealth-CHW home-based intervention in rural Rwanda and similar settings is feasible. Patients’ acceptance of the intervention was key to its success. The telemedicine-based SSI diagnosis had a high negative predictive value but a low sensitivity. Further studies must explore strategies to improve accuracy, such as accompanying wound images with clinical data or developing algorithms using machine learning.

Enablers and barriers to post-discharge follow-up among women who have undergone a caesarean section: experiences from a prospective cohort in rural Rwanda

Background

Caesarean sections account for roughly one third of all surgical procedures performed in low-income countries. Due to lack of standardised post-discharge follow-up protocols and practices, most of available data are extracted from clinical charts during hospitalization and are thus sub-optimal for answering post-discharge outcomes questions. This study aims to determine enablers and barriers to returning to the hospital after discharge among women who have undergone a c-section at a rural district hospital in Rwanda.

Methods

Women aged ≥ 18 years who underwent c-section at Kirehe District Hospital in rural Rwanda in the period March to October 2017 were prospectively followed. A structured questionnaire was administered to participants and clinical data were extracted from medical files between March and October 2017. At discharge, consenting women were given an appointment to return for follow-up on postoperative day 10 (POD 10) (± 3 days) and provided a voucher to cover transport and compensation for participation to be redeemed on their return. Study participants received a reminder call on the eve of their scheduled appointment. We used a backward stepwise logistic regression, at an α = 0.05 significance level, to identify enablers and barriers associated with post-discharge follow-up return.

Results

Of 586 study participants, the majority (62.6%) were between 21–30 years old and 86.4% had a phone contact number. Of those eligible, 90.4% returned for follow-up. The predictors of return were counselling by a female data collector (OR = 9.85, 95%CI:1.43–37.59) and receiving a reminder call (OR = 16.47, 95%CI:7.07–38.38). Having no insurance reduced the odds of returning to follow-up (OR = 0.03, 95%CI:0.03–0.23), and those who spent more than 10.6 Euro for transport to and from the hospital were less likely to return to follow-up (OR = 0.14, 95%CI:0.04- 0.50).

Conclusion

mHealh interventions using calls or notifications can increase the post-discharge follow-up uptake. The reminder calls to patients and discharge counselling by a gender-matching provider had a positive effect on return to care. Further interventions are needed targeting the uninsured and patients facing transportation hardship. Additionally, association between counselling of women patients by a female data collector and greater return to follow-up needs further exploration to optimize counselling procedures.

Supplementary information

The online version contains supplementary material available at 10.1186/s12913-022-08137-5.

Antibiotic Use, Incidence and Risk Factors for Orthopedic Surgical Site Infections in a Teaching Hospital in Madhya Pradesh, India

Orthopedic surgeries contribute to the overall surgical site infection (SSI) events worldwide. In India, SSI rates vary considerably (1.6−38%); however, there is a lack of a national SSI surveillance system. This study aims to identify the SSI incidence, risk factors, antibiotic prescription and susceptibility patterns among operated orthopedic patients in a teaching hospital in India. Data for 1205 patients were collected from 2013 to 2016. SSIs were identified based on the European Centre for Disease Prevention and Control guidelines. The American Society for Anesthesiologists classification system was used to predict patients’ operative risk. Univariable and multivariable backward stepwise logistic regressions were performed. Overall, 7.6% of patients developed SSIs over three years. The most common SSIs causative microorganism was Staphylococcus aureus (7%), whose strains were resistant to penicillin (100%), erythromycin (80%), cotrimoxazole (80%), amikacin (60%) and cefoxitin (60%). Amikacin was the most prescribed antibiotic (36%). Male sex (OR 2.64; 95%CI 1.32−5.30), previous hospitalization (OR 2.15; 95%CI 1.25−3.69), antibiotic prescription during hospitalization before perioperative antibiotic prophylaxis (OR 4.19; 95%CI 2.51−7.00) and postoperative length of stay > 15 days (OR 3.30; 95%CI 1.83−5.95) were identified as significant risk factors. Additionally, preoperative shower significantly increased the SSI risk (OR 4.73; 95%CI 2.72−8.22), which is unconfirmed in the literature so far.

A Fuzzy Inference System for the Assessment of Indoor Air Quality in an Operating Room to Prevent Surgical Site Infection

Indoor air quality in hospital operating rooms is of great concern for the prevention of surgical site infections (SSI). A wide range of relevant medical and engineering literature has shown that the reduction in air contamination can be achieved by introducing a more efficient set of controls of HVAC systems and exploiting alarms and monitoring systems that allow having a clear report of the internal air status level. In this paper, an operating room air quality monitoring system based on a fuzzy decision support system has been proposed in order to help hospital staff responsible to guarantee a safe environment. The goal of the work is to reduce the airborne contamination in order to optimize the surgical environment, thus preventing the occurrence of SSI and reducing the related mortality rate. The advantage of FIS is that the evaluation of the air quality is based on easy-to-find input data established on the best combination of parameters and level of alert. Compared to other literature works, the proposed approach based on the FIS has been designed to take into account also the movement of clinicians in the operating room in order to monitor unauthorized paths. The test of the proposed strategy has been executed by exploiting data collected by ad-hoc sensors placed inside a real operating block during the experimental activities of the “Bacterial Infections Post Surgery” Project (BIPS). Results show that the system is capable to return risk values with extreme precision.

Patient and Provider Preferences for Monitoring Surgical Wounds Using an mHealth App: A Formative Qualitative Analysis

Background: Surgical site infections complicate approximately 10% of all inpatient operations and account for nearly 20% of surgical re-admissions. Post-operative hospitalizations have become shorter over time, yet limited resources exist for patients to use at their home to communicate surgical wound problems with their medical providers. This study evaluated the attitudes of patients and providers towards using a remote wound monitoring application. Methods: This formative descriptive qualitative study reports the result of analysis of the interview content of five patients and five providers from a colorectal surgery clinic at the Medical University of South Carolina in Charleston, South Carolina. Semi-structured, face-to-face interviews were conducted in the clinic setting, were recorded, and professionally transcribed. Two of the authors independently reviewed and coded the transcribed interviews to identify themes across all 10 interviews. After independent coding, authors reviewed findings to reconcile and streamline the primary themes representing attitudes of patients and providers toward remote wound monitoring. Results: Five primary codes were found across our interviews: current barriers, infection types, workflow, interest in surgical site infection (SSI) monitoring, application considerations, and requested application features. We subcoded "symptom clarification" and "positive anticipation" under "interest in SSI monitoring," as well as "anticipated issues" and "application features" under "application considerations." From these codes, we synthesized findings into three overarching themes: smartphone app for remote wound monitoring has potential to improve patient-provider communication, specific wound evaluation processes are acceptable to patients and providers, and new collaboration with telehealth service is a welcome addition for interdisciplinary team management. Conclusions: A prospective approach to the development of a remote wound monitoring application enables a user-centric development process. Our analysis shows a readiness from both patients and providers to implement remote wound monitoring for identifying potential SSIs and coordinating surgical wound care within the community.

Risks and Prevention of Surgical Site Infection After Hernia Mesh Repair and the Predictive Utility of ACS-NSQIP

AIM

The aim of this paper was to provide a narrative review of surgical site infection after hernia surgery and the influence of perioperative preventative interventions.

METHODS

The review was based on current national and international guidelines and a literature search.

RESULTS

Mesh infection is a highly morbid complication after hernia surgery, and is associated with hospital re-admission, increased health care costs, re-operation, hernia recurrence, impaired quality of life and plaintiff litigation. The American College of Surgeons National Surgical Quality Improvement Program is a particularly useful resource for the study and evidence-based practise of abdominal wall hernia repair.

DISCUSSION

The three major modifiable patient comorbidities significantly associated with postoperative surgical site infection in hernia surgery are obesity, tobacco smoking and diabetes mellitus. Preoperative optimization includes weight loss, cessation of smoking, and control of diabetes. Intraoperative interventions relate, in particular, to the control of fomite mediated transmission in the operating theatre and prevention of mesh contamination with S. aureus CFUs. Risk management strategies should also target the niche ecological conditions which enable bacterial survival and subsequent biofilm formation on an implanted mesh. Outcomes of mesh infection after hernia surgery are closely related to mesh type and porosity, patient smoking status, presence of MRSA, bacterial adhesion and biofilm production. The use of suction drains and the timing of drain removal are controversial and discussed in detail. Finally, the utility of the ACS-NSQIP Surgical Risk Calculator in predicting complications and outcomes in individual patients and the importance of quality improvement initiatives in surgical units are emphasized.

Antimicrobial stewardship for surgical antibiotic prophylaxis and surgical site infections: a systematic review

Background Surgical site infections account for 14-17% of all healthcare-associated infections. Antimicrobial stewardship (AMS) are complementary strategies developed to optimize the use of antimicrobials. Aim to evaluate the effectiveness of AMS in promoting adherence to surgical antibiotic prophylaxis protocols in hospitalized patients, reducing surgical site infection rate and cost-benefit ratio. Method This systematic review of randomized clinical trials, non-randomized clinical trials and before and after studies was performed using Pubmed, Cochrane, Web of Science, Scopus, Embase, Google Scholar and ClinicalTrials.gov, in addition to reference lists of included studies. The risk of bias of studies was measured by the ROBINS-I checklist and the quality of the evidence synthesis by GRADE. Results Fourteen before and after design studies were included. In 85.7% of the studies, AMS was effective in increasing adherence to surgical antibiotic prophylaxis protocols and in 28.5%, there was reduction in surgical site infection rate. Three studies evaluated cost-benefit ratio and found a favorable impact. Eight (57%) studies were at risk of moderate bias and six had severe bias. The evaluation of the synthesis of evidence showed quality ranging from low to very low. Conclusion AMS, such as audit, feedback, education, implementation of a protocol, and a computer-assisted decision support methodology, appear to be effective in promoting adherence to surgical antibiotic prophylaxis protocols, reducing surgical site infection rate with a positive economic impact. However, more studies, particularly randomized clinical trials, are needed to improve the level of evidence of available information on AMS in order to favor decision-making.

Remote diagnosis of surgical-site infection using a mobile digital intervention: a randomised controlled trial in emergency surgery patients

Surgical site infections (SSI) cause substantial morbidity and pose a burden to acute healthcare services after surgery. We aimed to investigate whether a smartphone-delivered wound assessment tool can expedite diagnosis and treatment of SSI after emergency abdominal surgery. This single-blinded randomised control trial (NCT02704897) enroled adult emergency abdominal surgery patients in two tertiary care hospitals. Patients were randomised (1:1) to routine postoperative care or additional access to a smartphone-delivered wound assessment tool for 30-days postoperatively. Patient-reported SSI symptoms and wound photographs were requested on postoperative days 3, 7, and 15. The primary outcome was time-to-diagnosis of SSI (Centers for Disease Control definition). 492 patients were randomised (smartphone intervention: 223; routine care: 269). There was no significant difference in the 30-day SSI rate between trial arms: 21 (9.4%) in smartphone vs 20 (7.4%, p = 0.513) in routine care. Among the smartphone group, 32.3% (n = 72) did not utilise the tool. There was no significant difference in time-to-diagnosis of SSI for patients receiving the intervention (-2.5 days, 95% CI: -6.6-1.6, p = 0.225). However, patients in the smartphone group had 3.7-times higher odds of diagnosis within 7 postoperative days (95% CI: 1.02-13.51, p = 0.043). The smartphone group had significantly reduced community care attendance (OR: 0.57, 95% CI: 0.34-0.94, p = 0.030), similar hospital attendance (OR: 0.76, 95% CI: 0.28-1.96, p = 0.577), and significantly better experiences in accessing care (OR: 2.02, 95% CI: 1.17-3.53, p = 0.013). Smartphone-delivered wound follow-up is feasible following emergency abdominal surgery. This can facilitate triage to the appropriate level of assessment required, allowing earlier postoperative diagnosis of SSI.

Risk of surgical site infection in hand trauma, and the impact of the SARS-CoV-2 pandemic: A cohort study

BACKGROUND

Despite the ubiquity of hand trauma, there remains insufficient published data to reliably inform these patients of surgical site infection (SSI) risk. We describe the risk of SSI in a single-centre cohort of patients with hand trauma, with an analysis of the impact of the coronavirus disease-2019 (COVID-19) pandemic.

METHODS

Retrospective data collection of consecutive patients who underwent surgery for hand and wrist trauma in a single plastic surgery centre over two, three-month periods. Demographic, injury and operative details, alongside prophylactic antibiotic use, were recorded. Burn injuries and wounds infected at presentation were excluded. Presence of SSI at 30 days (90 days if a surgical implant was used) was assessed.

RESULTS

Overall, 556 patients - 'Pre-COVID-19' (n = 310) and 'During COVID-19' (n = 246) - were included. Risk of SSI was 3.6% in the aggregated cohort. Female patients were more likely to develop an SSI, even when adjusted for their greater prevalence of bite aetiologies (adj OR 2.5; 95% CI, 1.00-6.37 and p < 0.05). The absolute risk of SSI in the 'Pre-COVID-19' group was 2.3% and 5.3% in the 'During COVID-19' group. The relative risk of developing an SSI in the 'During COVID-19' group was 2.34 (95% CI, 0.95-5.78 and p = 0.06). Baseline characteristics were equivalent between the two groups.

CONCLUSION

The risk of SSI in hand trauma is the same as the nationally estimated risk for all surgeries; 3-5%. Changes in presentation and practice associated with the first wave of the COVID-19 pandemic did not appear to alter the risk of SSI in patients undergoing surgery for hand trauma.

Beyond the operating room: do hospital characteristics have an impact on surgical site infections after colorectal surgery? A systematic review

Background

Hospital characteristics have been recognized as potential risk factors for surgical site infection for over 20 years. However, most research has focused on patient and procedural risk factors. Understanding how structural and process variables influence infection is vital to identify targets for effective interventions and to optimize healthcare services. The aim of this study was to systematically review the association between hospital characteristics and surgical site infection in colorectal surgery.

Main body

A systematic literature search was conducted using PubMed, Scopus and Web of Science databases until the 31st of May, 2021. The search strategy followed the Participants, Exposure/Intervention, Comparison, Outcomes and Study design. The primary outcome of interest was surgical site infection rate after colorectal surgery. Studies were grouped into nine risk factor typologies: hospital size, ownership affiliation, being an oncological hospital, safety-net burden, hospital volume, surgeon caseload, discharge destination and time since implementation of surveillance. The STROBE statement was used for evaluating the methodological quality.

A total of 4703 records were identified, of which 172 were reviewed and 16 were included. Studies were published between 2008 and 2021, and referred to data collected between 1996 and 2016. Surgical site infection incidence ranged from 3.2 to 27.6%. Two out of five studies evaluating hospital size adjusted the analysis to patient and procedure-related risk factors, and showed that larger hospitals were either positively associated or had no association with SSI. Public hospitals did not present significantly different infection rates than private or non-profit ones. Medical school affiliation and higher safety-net burden were associated with higher surgical site infection (crude estimates), while oncological hospitals were associated with higher incidence independently of other variables. Hospital caseload showed mixed results, while surgeon caseload and surveillance time since implementation appear to be associated with fewer infections.

Conclusions

Although there are few studies addressing hospital-level factors on surgical site infection, surgeon experience and the implementation of a surveillance system appear to be associated with better outcomes. For hospitals and services to be efficiently optimized, more studies addressing these variables are needed that take into account the confounding effect of patient case mix.

Incidence and predictors of surgical site infection in women who are obese and give birth by elective caesarean section: A secondary analysis

BACKGROUND

Surgical site infection (SSI) after a caesarean section is of concern (CS) is of concern to both clinicians and women themselves.

AIMS

The aim of this study is to identify the cumulative incidence and predictors of SSI in women who are obese and give birth by elective CS.

MATERIALS AND METHODS

The method used was planned secondary analysis of data from women with a pre-pregnancy body mass index (BMI) ≥30 kg/m² giving birth by elective CS in a multicentre randomised controlled trial of a prophylactic closed-incision negative pressure wound therapy dressing. Data were collected from medical records, direct observations of the surgical site and self-reported signs and symptoms from October 2015 to December 2019. The Centers for Disease Control and Prevention definition was used to identify SSI. Women were followed up once in hospital just before discharge and then weekly for four weeks after discharge. Blinded outcome assessors determined SSI. After the cumulative incidence of SSI was calculated, multiple variable logistic regression models were used to identify independent risk factors for SSI.

RESULTS

SSI incidence in 1459 women was 8.4% (122/1459). Multiple variable-adjusted odds ratios (OR) for SSI were BMI ≥40 kg/m² (OR 1.55, 95% confidence interval (CI) 1.30-1.86) as compared to BMI 30-34.9 0 kg/m² , ≥2 previous pregnancies (OR 1.38, 95% CI 1.00-1.80) as compared to no previous pregnancies and pre-CS vaginal cleansing (OR 0.55, 95% CI 0.33-0.99).

CONCLUSIONS

Our findings may inform preoperative counselling and shared decision-making regarding planned elective CS for women with pre-pregnancy BMI ≥30 kg/m² .

Evaluating the post-discharge cost of healthcare-associated infection in NHS Scotland

BACKGROUND

Whereas the cost burden of healthcare-associated infection (HAI) extends beyond the inpatient stay into the post-discharge period, few studies have focused on post-discharge costs.

AIM

To investigate the impact of all types of HAI on the magnitude and distribution of post-discharge costs observed in acute and community services for patients who developed HAI during their inpatient stay.

METHODS

Using data from the Evaluation of Cost of Nosocomial Infection (ECONI) study and regression methods, this study identifies the marginal effect of HAI on the 90-daypost-discharge resource use and costs. To calculate monetary values, unit costs were applied to estimates of excess resource use per case of HAI.

FINDINGS

Post-discharge costs increase inpatient HAI costs by 36%, with an annual national cost of £10,832,437. The total extra cost per patient with HAI was £1,457 (95% confidence interval: 1,004-4,244) in the 90 days post discharge. Patients with HAI had longer LOS if they were readmitted and were prescribed more antibiotics in the community. The results suggest that HAI did not have an impact on the number of readmissions or repeat surgeries within 90 days of discharge. The majority (95%) of the excess costs was on acute care services after readmission. Bloodstream infection, gastrointestinal infection, and pneumonia had the biggest impact on post-discharge cost.

CONCLUSION

HAI increases costs and antibiotic consumption in the post-discharge period. Economic evaluations of IPC studies should incorporate post-discharge costs. These findings can be used nationally and internationally to support decision-making on the impact of IPC interventions.

Implementing enhanced patient education for surgical site infection prevention in cardiac surgery

OBJECTIVES

Photo at Discharge (PaD) is a nurse-led discharge strategy for enhanced wound care information for patients and healthcare providers. The purpose of this study is to describe implementation of PaD in three English cardiac centres.

METHODS

A prospective, cross-sectional design was used to evaluate implementation fidelity and sustainability of PaD on various geographical settings.

RESULTS

Three out of four hospitals (75%) approached agreed to complete surveys on implementation fidelity. Implementing the IT component took an average of 16 months (range 11-21 months). Across the three sites, 474 nursing staff have received training on PaD. Since implementing, a combined total of 9007 patients have received PaD. A 1-month compliance snapshot indicated mean of 96% (range 92-100%).

CONCLUSIONS

PaD requires collaborative working, a change in behaviour and a change to the service. Despite these challenges, fidelity and sustainability scores across the sites were high. The findings from this study may help to increase implementation quality and dissemination of PaD.

Clean Cut (adaptive, multimodal surgical infection prevention programme) for low-resource settings: a prospective quality improvement study

BACKGROUND

Clean Cut is an adaptive, multimodal programme to identify improvement opportunities and safety changes in surgery by enhancing outcomes surveillance, closing gaps in surgical infection prevention standards, and strengthening underlying processes of care. Surgical-site infections (SSIs) are common in low-income countries, so this study assessed a simple intervention to improve perioperative infection prevention practices in one.

METHODS

Clean Cut was implemented in five hospitals in Ethiopia from August 2016 to October 2018. Compliance data were collected from the operating room focused on six key perioperative infection prevention standards. Process-mapping exercises were employed to understand barriers to compliance and identify locally driven improvement opportunities. Thirty-day outcomes were recorded on patients for whom intraoperative compliance information had been collected.

RESULTS

Compliance data were collected from 2213 operations (374 at baseline and 1839 following process improvements) in 2202 patients. Follow-up was completed in 2159 patients (98·0 per cent). At baseline, perioperative teams complied with a mean of only 2·9 of the six critical perioperative infection prevention standards; following process improvement changes, compliance rose to a mean of 4·5 (P < 0·001). The relative risk of surgical infections after Clean Cut implementation was 0·65 (95 per cent c.i. 0·43 to 0·99; P = 0·043). Improved compliance with standards reduced the risk of postoperative infection by 46 per cent (relative risk 0·54, 95 per cent c.i. 0·30 to 0·97, for adherence score 3-6 versus 0-2; P = 0·038).

CONCLUSION

The Clean Cut programme improved infection prevention standards to reduce SSI without infrastructure expenses or resource investments.

Improving surgical site infection prevention in Asia-Pacific through appropriate surveillance programs: Challenges and recommendation

BACKGROUND

Surgical site infections (SSIs) represent a substantial clinical and economic burden on patients and the healthcare system. The prevention of SSIs entails surveillance activities which lead to effective mitigation strategies, which are lacking across Asia Pacific (APAC). This manuscript aims to document gaps and challenges across APAC that affect the undertaking of a successful SSI surveillance activities and to provide recommendations on overcoming such challenges.

METHODS

A targeted literature review with relevance to APAC identified a series of salient points pertaining to SSI prevention guidelines, implementation, surveillance and outcomes, which was discussed in July 2019 at the APAC Surgical Site Infection Prevention Symposium. An expert panel, comprising eight multidisciplinary experts from APAC and the USA, subsequently amalgamated the key discussion points from the Symposium and their clinical experiences in developing this article.

RESULTS

The barriers to implementing a successful and effective APAC SSI surveillance program were identified as: (a) lack of standardized definitions, reporting methodology and accountability, (b) lack of fiscal resources, (c) reporting variability and under-reporting, and (d) lack of safety culture. Implementing an effective surveillance program in APAC will require countries to develop a well-designed and robust surveillance plan and ensure adequate training for staffs involved.

CONCLUSION

To improve SSI prevention in the region, it is imperative to encourage implementation of national programs with standardized methodologies and accountabilities. An ongoing APAC information exchange, including data and methodologies, will enable continuous learning within the APAC region.

Management of superficial and deep surgical site infection: an international multidisciplinary consensus

Surgical site infections represent a considerable burden for healthcare systems. To obtain a consensus on the impact and future clinical and economic needs regarding SSI management in an era of multidrug resistance. A modified Delphi method was used to obtain consensus among experts from five European countries. The Delphi questionnaire was assembled by a steering committee, verified by a panel of experts and administered to 90 experts in 8 different surgical specialities (Abdominal, Cancer, Cardiac, General surgery, Orthopaedic, Thoracic, Transplant and Vascular and three other specialities (infectious disease, internal medicine microbiology). Respondents (n = 52) reached consensus on 62/73 items including that resistant pathogens are an increasing matter of concern and increase both treatment complexity and the length of hospital stay. There was strong positive consensus on the cost-effectiveness of early discharge (ED) programs, improvement of quality of life with ED and association between increased length of stay and economic burden to the hospital. However, established ED protocols were not widely available in their hospitals. Respondents expressed a positive consensus on the usefulness of antibiotics that allow ED. Surgeons are aware of their responsibility in an interdisciplinary team for the treatment of SSI, and of the impact of multidrug-resistant bacteria in the context of SSI. Reducing the length of hospital stays by applying ED protocols and implementing new treatment alternatives is crucial to reduce harm to patients and costs for the hospital.

The community burden of surgical site infection following elective colorectal resection

AIM

Surgical site infection (SSI) is common after colorectal surgery. Recent attempts to measure SSI have focused on inpatient SSI and readmissions. This study examined patient-reported SSI at 30 days over 8 years.

METHODS

The Health Protection Agency questionnaire was used to prospectively measure 30-day patient-reported SSI in patients undergoing elective colorectal operations between February 2011 and April 2019. Questionnaires were sent by post and followed up with a phone call. Data relating to hospital stay were prospectively recorded on an enhanced recovery database.

RESULTS

In all, 80.7% (1268) of 1559 patients responded to the questionnaire with an overall SSI rate of 15.9% (201/1268). The majority of patients who reported SSI presented in the community (66.7%) of whom 65% consulted their general practitioner and 35% saw a community nurse. Patient-reported SSI was validated by a health professional in over 90% of cases. Overall, only 1.5% of readmissions and 2% of ward attendances were due to an isolated wound problem. Patients who developed SSI during their index admission had a longer length of stay (11 days vs. 4 days) but there was no difference in delayed discharge or complications between patients with and without SSI, suggesting that a previously described association between SSI and increased length of stay may be due to observational bias.

CONCLUSION

Existing surveillance audits are suboptimal for monitoring SSIs following colorectal surgery as most SSIs present after discharge. There is a need for robust 30-day surveillance with a standardized methodology if comparisons are to be made between units.

What gets measured gets noticed. Tracking surgical site infection post caesarean section through community surveillance: A post intervention study protocol

AIM

This study aims to evaluate the effectiveness of HealthTracker, a surgical site infection surveillance system that aims to improve the notification of surgical site infection for women after giving birth by caesarean section.

DESIGN

This protocol is an intervention study to evaluate the effectiveness of the surveillance system called "HealthTracker" in monitoring surgical site infections post caesarean section.

METHODS

This study will use a mobile web application to automatically send a text message inviting all women who give birth to a live baby by caesarean section over six months during 2020-2021, at an Australian tertiary referral hospital. The text message invites women to complete a web-based validated Wound Healing Questionnaire. The estimated number of eligible women in six months is 700 (caesarean section rate: 34% of 4,000 births annually).

INTERVENTION

the proposed "HealthTracker" surveillance system facilitates active patient-reported surgical site infection identification through an automated mobile text message linking women to an individualized online Wound Healing Questionnaire.

DISCUSSION

This project aims to provide a consistent, reliable and cost effective surgical site infection surveillance tool to improve post caesarean section surgical site infection reporting, can be scaled for broader utilization and will provide valuable information to decision makers regarding surgical site infection prevention.

IMPACT

Study findings will provide insights into whether HealthTracker is an efficient and cost effective platform for a systematic and consistent approach to surgical site infection surveillance that can be adopted more broadly, across the local health organization, the State and across other surgical specialty areas. This information will equip hospitals and clinicians with knowledge to better identify patient outcomes related to SSI post discharge from hospital and inform decision making related to preventative strategies, providing the necessary momentum to introduce practice change initiatives aimed at reducing surgical site infection rates.

TRIAL REGISTRATION

ACTRN12620001233910.

Assessing completeness of patient medical records of surgical and obstetric patients in Northern Tanzania

Background

Strengthening surgical services in resource-constrained settings is contingent on using high-quality data to inform decision making at clinical, facility, and policy levels. However, the evidence is sparse on gaps in paper-based medical record quality for surgical and obstetric patients in low-resource settings.

Objective

We aim to examine surgical and obstetric patient medical record data quality in health facilities as part of a surgical system strengthening initiative in northern Tanzania.

Methods

To measure the incidence of Surgical Site Infections (SSIs), sepsis and maternal sepsis surgical and obstetric inpatients were followed prospectively, over three months in ten primary, district, and regional health facilities in northern Tanzania. Between April 22nd to May 1st, 2018, we retrospectively reviewed paper-based medical records of surgical and obstetric patients diagnosed with SSIs, post-operative sepsis, and maternal sepsis in the three-month follow-up period. A data quality assessment tool with18 data elements related to documentation of SSIs and sepsis diagnosis, their respective symptoms and vital signs, inpatient daily monitoring indicators, and demographic information was developed and used to assess the completeness of patient medical records.

Results

Among the 157 patients diagnosed with SSI and sepsis, we found and reviewed 68% of all medical records. Among records reviewed, approximately one third (34%) and one quarter (23%) included documentation of SSI and sepsis diagnoses, respectively. 6% of reviewed records included documentation of all SSI and sepsis diagnoses, symptoms and vital signs, inpatient daily monitoring indicators, and demographic data.

Conclusions

Strengthening data quality and record-keeping is essential for surgical team communication, continuity of care, and patient safety, especially in low resource settings where paper-based records are the primary means of data collection. High-quality primary health information provides facilities with actionable data for improving surgical and obstetric care quality at the facility level.

Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution

Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.

Relationships between predischarge and postdischarge infectious complications, length of stay, and unplanned readmissions in the ACS NSQIP database

BACKGROUND

Postoperative complications, length of index hospital stay, and unplanned hospital readmissions are important metrics reflecting surgical care quality. Postoperative infections represent a substantial proportion of all postoperative complications. We examined the relationships between identification of postoperative infection prehospital and posthospital discharge, length of stay, and unplanned readmissions in the American College of Surgeons National Surgical Quality Improvement Program database across nine surgical specialties.

METHODS

The 30-day postoperative infectious complications including sepsis, surgical site infections, pneumonia, and urinary tract infection were analyzed in the American College of Surgeons National Surgical Quality Improvement Program inpatient data during the period from 2012 to 2017. General, gynecologic, vascular, orthopedic, otolaryngology, plastic, thoracic, urologic, and neurosurgical inpatient operations were selected.

RESULTS

Postoperative infectious complications were identified in 5.2% (137,014/2,620,450) of cases; 81,929 (59.8%) were postdischarge. The percentage of specific complications identified postdischarge were 73.4% of surgical site infections (range across specialties 63.7-93.1%); 34.9% of sepsis cases (27.4-58.1%); 26.5% of pneumonia cases (18.9%-36.3%); and 53.2% of urinary tract infections (48.3%-88.0%). The relative risk of readmission among patients with postdischarge versus predischarge surgical site infection, sepsis, pneumonia, or urinary tract infection was 5.13 (95% confidence interval: 4.90-5.37), 9.63 (8.93-10.40), 10.79 (10.15-11.45), and 3.32 (3.07-3.60), respectively. Over time, mean length of stay decreased but postdischarge infections and readmission rates significantly increased.

CONCLUSION

Most postoperative infectious complications were diagnosed postdischarge. These were associated with an increased risk of readmission. The trend toward shorter length of stay over time was observed along with an increase both in the percentage of infections detected after discharge and the rate of unplanned related postoperative readmissions over time. Postoperative surveillance of infections should extend beyond hospital discharge of surgical patients.

Reliability and feasibility of registered nurses conducting web-based surgical site infection surveillance in the community: A prospective cohort study

Surgical site infections increase health care costs, morbidity, and mortality in 2% to 5% of surgical patients. Standardised post-surgical surveillance is rare in community settings, causing under-reporting and under-serving of the documented 60% of surgical site infections occurring following hospital discharge. This study evaluated feasibility and concordance (inter-rater reliability) of paired registered nurses using a web-based surveillance tool (how2trakSSI, based on validated guidelines) to detect surgical site infections for up to 30 days after surgery in a cohort of 101 patients referred to Calea Home Care Clinics in Toronto, Canada, March 2015 to July 2016. After paired registered nurse assessors used the tool-less than 10 minutes apart to measure concordance 5 to 7 days postoperatively, they provided feedback on its usefulness at two teleconference discussion groups September 6 to 7, 2016. Overall concordance between assessors was 0.822, remaining consistently above 0.65 across assessor education level and experience, patient age and weight, and wound area. Assessors documented 39.6% surgical site infection prevalence 5 to 7 days after surgery, confirming clinical need, relevance, reliability, and feasibility of using this web-based tool to standardise community surgical site infection surveillance, noting that it was user-friendly, more efficient to use than traditional paper-based tools and useful as a registry for tracking progress.

Practice of and associated factors regarding prevention of surgical site infection among nurses working in the surgical units of public hospitals in Addis Ababa city, Ethiopia: A cross-sectional study

Background

Surgical site infections are one of the commonest types of healthcare-associated infections. Up to 60% of these infections are estimated to be preventable by using evidence-based guidelines. As a front line caregiver, nurses are responsible for the majority of preventive activities. Hence, the enhanced practical skill of nurses is an essential component in preventive actions.

Objective

The aim of this study was to assess the practice of nurses and identify factors associated with it regarding prevention of surgical site infections in Addis Ababa city public hospitals.

Methods

An institution-based cross-sectional study was carried out from March 01–30, 2018. An adapted and pretested, self-administered questionnaire was utilized as a data collection tool. A stratified random sampling technique was employed by considering the level of hospitals as a stratum. Data were entered into a computer using Epi-data 3.1 statistical package. Then, it was exported to SPSS Version 23 for further analysis. Descriptive statistics were computed for the study variables. Bivariate regression analysis was also run to assess the association between independent variables and the level of nurse’s practice. To see the relative effect of independent variables on the nurse’s practice, a multivariable regression analysis was carried out.

Result

A total of 409 nurses returned the questionnaire with a response rate of 98%. Majority (60.4%) of the participants were females and 84.1% were BSc holders. Less than half, (48.9%) of the participants were found to have good practice regarding prevention of surgical site infection. Being male, having more work experience, higher educational level and using available infection prevention guidelines were significantly associated with practice at p <0.05.

Conclusion

More than half of the participants have inadequate practice regarding prevention of surgical site infection. Training nurses, making surgical site infection prevention guidelines easily accessible and ensuring possessed knowledge by nurses is potent enough and can be translated into desirable actions are recommended.

Post-discharge surveillance of surgical site infections in teaching hospitals in Brazil

OBJECTIVE

Understanding the reality of surgical site infections post-discharge surveillance in Brazilian teaching hospitals.

METHOD

A cross-sectional study conducted by sending an online questionnaire to nurses from the Hospital Infection Control Committee of Brazilian teaching hospitals registered in the National Registry of Health Establishments.

RESULTS

Of the 193 teaching hospitals in Brazil, eight declined to take part as they did not conduct post-discharge surveillance and 36 did not respond. Twenty five of the remaining 149 hospitals provided detailed responses and 96% of responding institutions performed surgical site infection surveillance during hospitalization; active search (29.3%) was the main method, while 84% reported performing post-discharge surveillance mainly by telephone (42.8%). Both surveillance actions have nurses as the main responsible professionals.

CONCLUSION

Nurses play a prominent role in surgical site infection identification/screening actions, and active search during hospitalization allied with post-discharge surveillance by telephone were the preferred methods.

Air quality in the operating room: Surgical site infections, HVAC systems and discipline - position paper of the German Society of Hospital Hygiene (DGKH)

In recent years, there has been an ongoing discussion about the value of laminar airflow (LAF=low turbulence displacement ventilation) in the operating room for prevention of surgical site infections (SSI). Some publications, e.g., from the WHO, issued the demand to no longer build LAF ceilings in operating rooms. The present statement deals critically with this position and justifies the use of LAF ceilings in different ways: Many of the papers cited by the WHO and others for the case against LAF do not provide reliable data.The remaining studies which might be used for answering the question give quite different results, also in favor of LAF.The size of the LAF ceiling in many studies is not given or mostly too small in comparison to actual technical requirements.LAF in different countries can mean quite different techniques (e.g., the US in comparison to Germany) so that the results of studies that do not take this into account may not be comparable.LAF has positive effects in terms of reducing particulate and bacterial load, associated with increased airflow in the surgical working area. A reduction of carcinogenic substances in the air may also be assumed, which would increase workers' safety. Thus, this paper recommends building LAF ceilings in the future as well, depending on the operations intended. Further, this paper gives an overview of possible reasons for surgical site infections and highlights the importance of discipline in the operating theatre.

Process and outcome indicators for infection control and prevention in European acute care hospitals in 2011 to 2012 - Results of the PROHIBIT study

Hospitals from 24 European countries were asked for information on infection prevention and control (IPC) indicators as part of the Prevention of Hospital Infections by Intervention and Training (PROHIBIT) survey. Methods: Leading IPC personnel of 297 hospitals with established healthcare-associated infection (HCAI) surveillance provided information on local surveillance and feedback by using a questionnaire. Results: Most hospitals focused on bloodstream infection (BSI) (n = 251) and surgical site infection (SSI) (n = 254), with a SSI post-discharge surveillance in 148 hospitals. As part of the HCAI surveillance, meticillin-resistant Staphylococcus aureus (MRSA) was the leading multidrug-resistant organism (MDRO) under surveillance. Seventy-nine per cent of hospitals (n = 236) monitored alcohol-based hand rub (ABHR) consumption. Feedback to the local IPC committees mainly included outcome data on HCAI (n = 259; 87%) and MDRO among HCAI (n = 245; 83%); whereupon a feedback of MDRO data depended on hospital size (p = 0.012). Discussion/conclusion: Objectives and methods of surveillance vary across Europe, with BSI, SSI and MRSA receiving considerably more attention than indicators such as pneumonia and urinary tract infection, which may be equally important. In order to maximise prevention and control of HCAI and MDRO in Europe, surveillance should be further improved by targeting relevant HCAI. The role of feedback should be explored in more detail.

Engaging Patients in Co-Design of Mobile Health Tools for Surgical Site Infection Surveillance: Implications for Research and Implementation

Background: As the use of patient-owned devices, including smartphones and tablets, to manage day-to-day activities grows, so does healthcare industry's interest to better leverage technology to engage patients. For surgical care, a unique opportunity exists to capture patient-generated health data (PGHD) including photographs. As part of a broader initiative to evaluate PGHD for surgical site infection (SSI) surveillance, we sought evidence regarding patient involvement and experience with PGHD for SSI monitoring and surveillance. Methods: Through a scoping review of the literature and semi-structured stakeholder interviews we gathered evidence on what is currently known about patient perspectives of and experiences with mobile health (mHealth) interventions for post-operative recovery. We presented findings to and discussed with the ASSIST PGHD Stakeholder Advisory Group (PSAG) to generate priorities for further examination. Results: Our scoping review yielded 34 studies that addressed post-discharge use of PGHD for monitoring and surveillance of SSI. Of these, 16 studies addressed at least one outcome regarding patient experience; the most commonly measured outcome was patient satisfaction. Only three studies reported on patient involvement in the development of PGHD tools and interventions. We conducted interviews (n = 24) representing a range of stakeholder perspectives. Interviewees stressed the importance of patient involvement in tool and program design, noting patient involvement ensures the "work" that patients do in their daily lives to manage their health and healthcare is recognized. Discussion of evidence with the ASSIST PSAG resulted in formal recommendations for direct involvement of patients and caregivers for future work. Conclusions: While mHealth initiatives to advance post-operative management offer the ability to improve patient engagement, work is needed to ensure the patient voice is reflected. Active engagement with patients and caregivers in the development of new technology, the design of new workflows, and the conduct of research and evaluation ensures that the patient experiences and values are incorporated.

Patient-Generated Health Data in Surgical Site Infection: Changing Clinical Workflow and Care Delivery

Background: The patient's history of present illness provides an important part of the data with which clinicians diagnose and treat. Once surgical patients are discharged, the ability to incorporate direct observation requires coordinating patient and provider for a clinical visit. Mobile technologies offer the ability to gather and organize the patient's history, supplement that history with photographs and other clinical observations, and convey those data accurately and rapidly to the entire clinical team. Methods: We review our experience with patient-generated health data in surgical site infection, draw parallels with similar work in other domains, and identify principles we have found useful. Results: Health information system implementations require substantial changes in provider workflow. Shared expectations between the patient and the surgical team, an incremental approach to change in clinical processes, and an emphasis on clinical utility all support successful implementation. Conclusions: The data collection and rapid information exchange afforded by monitoring post-operative, post-discharge patients using mobile technologies can support the expectations of both patients and providers and may provide a novel data source for public health surveillance of surgical site infection. Both uses of these data require careful attention to introducing changes in clinical workflow.