Effect of preoperative hospital stay on surgical site infection in Chinese cranial neurosurgery

OBJECTIVE

Surgical site infection(SSI)after neurosurgical procedure can be devastating. Delayed hospital stay has been identified as a potentially modifiable driver of SSI in general surgery patients. However, the relationship between preoperative length of stay and SSI has not been quantified previously in neurosurgery. This study aimed to clarify the association.

DESIGN

A Cohort study based on STROBE checklist.

METHOD

This observational study focused on cranial neurosurgery patients at a tertiary referral centers in China. Data collection from hospital information system conducted between 1 January 2016 and 31 December 2016 was used to examine the results of interest (n = 600). Logistic regression analysis explored association between preoperative length of stay and SSI, adjusting for potential confounders.

RESULTS

Overall SSI prevalence was 10.8% and was significantly higher in the longer preoperative length of stay group. Besides preoperative length of stay, American Society of Anesthesiologists score, type of surgery, gross blood loss also significantly associated with SSI prevalence. Compared with 1 to 2 days, longer preoperative length of stay was associated with increased SSI prevalence after adjustment for confounders (3 to 4 days: odds ratio[OR], 0.975[95%CI, 0.417 to 2.281]; 5 to 6 days: OR, 2.830[95%CI, 1.092 to 7.332]; 7 or more days: OR, 4.039[95%CI, 1.164 to 14.015]; P for trend < 0.001). On the other hand, we found a positive association between preoperative length of stay to deep/space-organ SSI (OR = 1.404; 95% CI: 1.148 to 1.717; P for trend < 0.001), which was higher than superficial SSI (OR = 1.242; 95% CI: 0.835 to1.848; P for trend= 0.062).

CONCLUSIONS

In a cohort of patients from a single center retrospective surgical registry, a longer preoperative length of stay was associated with a higher incidence of cranial neurosurgical SSI. There is room for improvement in preoperative length of stay. This can be used for hospital management and to stratify patients with regard to SSI risk.

The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience

BACKGROUND

Surgical quality improvement programs can provide meaningful benefits for patient outcomes, but sustainability of initial success is rarely described. In response to data that revealed a greater than predicted likelihood of postoperative pulmonary complications in one hospital, the study team designed a standardized program to improve care. This study offers a long-term perspective of the effort, including special challenges and lessons learned about sustaining success.

METHODS

A before-after study was conducted at an academic safety-net hospital. A multidisciplinary team developed tactics to reduce pulmonary complications, designated by the acronym I COUGH: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (education), Getting out of bed, and Head of bed elevation. Clinical practices were audited and compared to actual and risk-adjusted pulmonary outcomes.

RESULTS

Improvements in compliance with the I COUGH elements were initially promising, but baseline behaviors eventually returned. Adverse outcomes have inversely correlated with process adherence in "sawtooth" patterns. Rejuvenation efforts have successively extended beyond the literal principles of the acronym to foster broader institutional commitment to perioperative pulmonary care, restoring favorable trends in both process and outcomes. A more comprehensive I COUGH program now extends beyond the acronym, applying numerous concepts to support the original program.

CONCLUSION

I COUGH, a standardized perioperative pulmonary care program, initially improved performance and reduced pulmonary complications. However, loss of early program momentum corresponded with a return to baseline outcomes. Fortunately, an overall favorable trend has resulted from a coordinated rededication to I COUGH that requires steadfast commitment and creative responses to numerous cultural barriers.

The evaluation of the implementation of the vascular preventative bundle and development of suggested interventions for improvement and sustainability

Postoperative infections can complicate patient care and increase health care costs. A vascular preventative bundle was implemented at a large teaching/research intensive hospital to decrease surgical site infections (SSIs) with vascular surgery patients. The aim of this study was to measure fidelity to the bundle and determine if implementation of the vascular SSI bundle reduced the rate of SSIs. Three periods of data were collected, and they are identified as preimplementation (period 1), early implementation (period 2), and postimplementation (period 3). There were 711 patients for all three periods, approximately equally distributed in the periods. The use of preoperative hair clippings, chlorhexidine (CHG) wipes, and appropriate antibiotics showed the greatest improvement from preimplementation to early implementation. All three measures showed significant improvements in fidelity. For appropriate antibiotics, the fidelity was the highest and showed the largest improvement compared to the other measures. The performance of clippings preoperatively and using CHG wipes improved significantly. Evidence-based interventions have been recommended to support the implementation and sustainability of the bundle. The infection rate between preop and postperiod was not statistically different.

Change in Adverse Events After Enrollment in the National Surgical Quality Improvement Program: A Systematic Review and Meta-Analysis

Background

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and compare the quality of surgical care across North America. Participation in this program may provide an opportunity to reduce the incidence of adverse events related to surgery.

Study Design

A systematic review of the literature was performed. MedLine, EMBASE and PubMed were searched for studies relevant to NSQIP. Patient characteristics, intervention, and primary outcome measures were abstracted. The intervention was participation in NSQIP and monitoring of Individual Site Summary Reports with or without implementation of a quality improvement program. The outcomes of interest were change in peri-operative adverse events and mortality represented by pooled risk ratios (pRR) and 95% confidence intervals (CI).

Results

Eleven articles reporting on 35 health care institutions were included. Nine (82%) of the eleven studies implemented a quality improvement program. Minimal improvements in superficial (pRR 0.81; 95% CI 0.72–0.91), deep (pRR 0.82; 95% CI0.64–1.05) and organ space (pRR 1.15; 95% CI 0.96–1.37) infections were observed at centers that did not institute a quality improvement program. However, centers that reported formal interventions for the prevention and treatment of infections observed substantial improvements (superficial pRR 0.55, 95% CI 0.39–0.77; deep pRR 0.61, 95% CI 0.50–0.75, and organ space pRR 0.60, 95% CI 0.50–0.71). Studies evaluating other adverse events noted decreased incidence following NSQIP participation and implementation of a formal quality improvement program.

Conclusions

These data suggest that NSQIP is effective in reducing surgical morbidity. Improvement in surgical quality appears to be more marked at centers that implemented a formal quality improvement program directed at the reduction of specific morbidities.

Medicare claims can be used to identify US hospitals with higher rates of surgical site infection following vascular surgery

BACKGROUND

Surgical site infections (SSIs) following vascular surgery have high morbidity and costs, and are increasingly tracked as hospital quality measures.

OBJECTIVE

To assess the ability of Medicare claims to identify US hospitals with high SSI rates after vascular surgery.

RESEARCH DESIGN

Using claims from fee-for-service Medicare enrollees of age 65 years and older who underwent vascular surgery from 2005 to 2008, we derived hospital rankings using previously validated codes suggestive of SSI, with individual-level adjustment for age, sex, and comorbidities. We then obtained medical records for validation of SSI from hospitals ranked in the best and worst deciles of performance, and used logistic regression to calculate the risk-adjusted odds of developing an SSI in worst-decile versus best-decile hospitals.

RESULTS

Among 203,023 Medicare patients who underwent vascular surgery at 2512 US hospitals, a patient undergoing surgery in a hospital ranked in the worst-performing decile based on claims had 2.5 times higher odds of developing a chart-confirmed SSI relative to a patient with the same age, sex, and comorbidities in a hospital ranked in the best-performing decile (95% confidence interval, 2.0-3.1). SSI confirmation among patients with claims suggesting infection was similar across deciles, and we found similar findings in analyses limited to deep and organ/space SSIs. We report on diagnosis codes with high sensitivity for identifying deep and organ/space SSI, with one-to-one mapping to ICD-10-CM codes.

CONCLUSIONS

Claims-based surveillance offers a standardized and objective methodology that can be used to improve SSI surveillance and to validate hospitals' publicly reported data.

Improving service uptake and quality of care of integrated maternal health services: the Kenya Kwale District improvement collaborative

BACKGROUND

Health-related millennium development goals are off track in most of the countries in the sub-Saharan African region. Lack of access to, and low utilization of essential services and high-impact interventions, together with poor quality of health services, may be partially responsible for this lack of progress. We explored whether improvement approaches can be applied to increase utilization of antenatal care (ANC), health facility deliveries, prevention of mother-to-child transmission services and adherence to ANC standards of care in a rural district in Kenya. We targeted improvement of ANC services because ANC is a vital point of entry for most high-impact interventions targeting the pregnant mother.

METHODS

Healthcare workers in 21 public health facilities in Kwale District, Kenya formed improvement teams that met regularly to examine performance gaps in service delivery, identify root causes of such gaps, then develop and implement change ideas to address the gaps. Data were collected and entered into routine government registers by the teams on a daily basis. Data were abstracted from the government registers monthly to evaluate 20 indicators of care quality for improvement activities. For the purposes of this study, aggregate data for the district were collected from the District Health Management Office.

RESULTS

The number of pregnant mothers starting ANC within the first trimester and those completing at least four ANC checkups increased significantly (from 41 (8%) to 118 (24%) p=0.002 and from 186 (37%) to 316 (64%) p<0.001, respectively). The proportions of ANC visits in which provision of care adhered to the required standards increased from <40% to 80-100% within three to six months (X2 for trend 4.07, p<0.001). There was also a significant increase in the number of pregnant women delivering in health facilities each month from 164 (33%) to 259 (52%) (p=0.012).

CONCLUSION

Improvement approaches can be applied in rural health care facilities in low-income settings to increase utilization of services and adherence to standards of care. Using the quality improvement methodology to target integrated health services is feasible. Longer follow-up periods are needed to gather more evidence on the sustainability of quality improvement initiatives in low-income countries.

Risk-adjusted hospital outcomes for children's surgery

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children's surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance.

METHODS

Participating institutions included children's units within general hospitals and free-standing children's hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models.

RESULTS

In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible.

CONCLUSIONS

The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children's surgery performance indicator. Programmatic improvements have resulted in actionable data.