1
|
Gao C, Wang H, Ju J, Zhang K, Gao Y, Guo S, Yin D, Hou R, Guo Q. Distribution of pathogens and risk factors for post-replantation wound infection in patients with traumatic major limb mutilation. PLoS One 2024; 19:e0301353. [PMID: 38558019 PMCID: PMC10984543 DOI: 10.1371/journal.pone.0301353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
PURPOSE Even though replantation of limb mutilation is increasing, postoperative wound infection can result in increasing the financial and psychological burden of patients. Here, we sought to explore the distribution of pathogens and identify risk factors for postoperative wound infection to help early identification and managements of high-risk patients. METHODS Adult inpatients with severed traumatic major limb mutilation who underwent replantation from Suzhou Ruixing Medical Group between November 09, 2014, and September 6, 2022 were included in this retrospective study. Demographic, and clinical characteristics, treatments, and outcomes were collected. Data were used to analyze risk factors for postoperative wound infection. RESULTS Among the 249 patients, 185 (74.3%) were males, the median age was 47.0 years old. Postoperative wound infection in 74 (29.7%) patients, of whom 51 (20.5%) had infection with multi-drug resistant bacteria. Ischemia time (OR 1.31, 95% CI 1.13-1.53, P = 0.001), wound contamination (OR 6.01, 95% CI 2.38-15.19, P <0.001), and stress hyperglycemia (OR 23.37, 95% CI 2.30-236.93, P = 0.008) were independent risk factors, while the albumin level after surgery (OR 0.94, 95% CI 0.89-0.99, P = 0.031) was significant associated with the decrease of postoperative wound infection. Ischemia time (OR 1.21, 95% CI 1.05-1.40, P = 0.010), wound contamination (OR 8.63, 95% CI 2.91-25.57, P <0.001), and MESS (OR 1.32, 95% CI 1.02-1.71, P = 0.037 were independent risk factors for multi-drug resistant bacteria infection. CONCLUSIONS Post-replantation wound infection was common in patients with severe traumatic major limb mutilation, and most were multi-drug resistant bacteria. Ischemia time and wound contamination were associated with the increase of postoperative wound infection, including caused by multi-drug resistant. Positive correction of hypoproteinemia and control of stress hyperglycemia may be beneficial.
Collapse
Affiliation(s)
- Chang Gao
- Department of Emergency and Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Haiyan Wang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Jihui Ju
- Department of Orthopaedic, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Keran Zhang
- Department of Critical Care Medicine, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Ye Gao
- Department of Critical Care Medicine, Taicang Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shiqi Guo
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Di Yin
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Ruixing Hou
- Department of Orthopaedic, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Qiang Guo
- Department of Emergency and Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
- The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| |
Collapse
|
2
|
Yusuf Y, Abdallah M, Episcopia B, Fornek M, Quale J. Do risk adjustment calculations used by governmental agencies adequately assess risk for infection after colon surgery? Am J Infect Control 2024; 52:463-467. [PMID: 37898319 PMCID: PMC11018117 DOI: 10.1016/j.ajic.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/18/2023] [Accepted: 10/21/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) following colon surgery are associated with clinical and financial consequences. The Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) use risk adjustment variables to determine quality measure scores. METHODS Among patients in a large public system, surgical risk variables were compared between patients with and without SSIs. Propensity score matching, using CMS and NYSDOH risk variables, created control groups. Receiver Operating Characteristics (ROC) curves were created using current and augmented risk adjustment variables. RESULTS When matched using CMS risk variables, more patients with SSIs had contaminated/dirty wounds, longer duration of surgery, and emergency surgery. The addition of these variables significantly improved the CMS ROC curve. When matching NYSDOH variables, more SSI patients were male, had contaminated/dirty wounds, and tended to be younger. The addition of these variables to the current NYSDOH adjustment criteria did not significantly improve the ROC curve. DISCUSSION The CMS adjustment criteria for colon SSIs do not adequately account for complicated surgeries. The inclusion of additional variables significantly improved the performance of CMS risk adjustment. CONCLUSIONS Until more robust risk adjustment criteria are developed, the reporting of SSIs following colon surgery as a quality measure should be suspended.
Collapse
Affiliation(s)
- Yasna Yusuf
- Department of Medicine, NYC Health+Hospitals/Kings County, Brooklyn, NY
| | - Marie Abdallah
- Department of Ambulatory Care, NYC Health+Hospitals/Kings County, Brooklyn, NY.
| | - Briana Episcopia
- Department of Infection Prevention, NYC Health+Hospitals/Kings County, Brooklyn, NY
| | - Mary Fornek
- Department of Infection Prevention, NYC Health+Hospitals/Central Office, New York, NY
| | - John Quale
- Department of Medicine, NYC Health+Hospitals/Kings County, Brooklyn, NY
| |
Collapse
|
3
|
Fornek ML, Ata S, Jimenez E, Abdallah M, Sunny S, Lee J, Episcopia B, Roudnitsky V, Quale J. Reportable infections following colon surgery in a large public healthcare system in New York City: The consequences of being a level 1 trauma center. Infect Control Hosp Epidemiol 2024; 45:21-26. [PMID: 37462117 PMCID: PMC11018097 DOI: 10.1017/ice.2023.150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
OBJECTIVES To examine differences in risk factors and outcomes of patients undergoing colon surgery in level 1 trauma centers versus other hospitals and to investigate the potential financial impact of these reportable infections. DESIGN Retrospective cohort study between 2015 and 2022. SETTING Large public healthcare system in New York City. PARTICIPANTS All patients undergoing colon surgery; comparisons were made between (1) all patients undergoing colon surgery at the level 1 trauma centers versus patients at the other hospitals and (2) the nontrauma and trauma patients at the level 1 trauma centers versus the nontrauma patients at other hospitals. RESULTS Of 5,217 colon surgeries reported, 3,531 were at level 1 trauma centers and 1686 at other hospitals. Patients at level 1 trauma centers had significantly increased American Society of Anesthesiology (ASA) scores, durations of surgery, rates of delayed wound closure, and rates of class 4 wounds, resulting in higher SIRs (1.1 ± 0.15 vs 0.75 ± 0.18; P = .0007) compared to the other hospitals. Compared to the nontrauma patients at the other hospitals, both the nontrauma and trauma patients at the level 1 trauma centers had higher ASA scores, rates of delayed wound closure, and of class 4 wounds. The SIRs of the nontrauma patients (1.16 ± 1.29; P = .008) and trauma patients (1.26 ± 2.69; P = .066) at the level 1 trauma center were higher than the SIRs of nontrauma patients in the other hospitals (0.65 ± 1.18). CONCLUSIONS Patients undergoing colon surgery at level 1 trauma centers had increased complexity of surgery compared to the patients in other hospitals. Until there is appropriate adjustment for these risk factors, the use of infections following colon surgery as a reportable quality measure should be re-evaluated.
Collapse
Affiliation(s)
- Mary L. Fornek
- Department of Infection Prevention, NYC Health+Hospitals/Central Office, New York, New York
| | - Subhan Ata
- Department of Medicine, NYC Health+Hospitals/Kings County, Brooklyn, New York
| | - Edwin Jimenez
- Department of Surgery, NYC Health+Hospitals/Kings County, Brooklyn, New York
| | - Marie Abdallah
- Department of Ambulatory Care, NYC Health+Hospitals/Kings County, Brooklyn, New York
| | - Subin Sunny
- Department of Ambulatory Care, NYC Health+Hospitals/Kings County, Brooklyn, New York
| | - Jennifer Lee
- Department of Ambulatory Care, NYC Health+Hospitals/Kings County, Brooklyn, New York
| | - Briana Episcopia
- Department of Infection Prevention, NYC Health+Hospitals/Kings County, Brooklyn, New York
| | - Valery Roudnitsky
- Department of Surgery, NYC Health+Hospitals/Kings County, Brooklyn, New York
| | - John Quale
- Department of Medicine, NYC Health+Hospitals/Kings County, Brooklyn, New York
| |
Collapse
|
4
|
Lagazzi E, Proaño-Zamudio JA, Argandykov D, Rafaqat W, Abiad M, Romijn AS, van Ee EPX, Velmahos GC, Kaafarani HMA, Hwabejire JO. Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery. Surg Infect (Larchmt) 2023; 24:869-878. [PMID: 38011709 DOI: 10.1089/sur.2023.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.
Collapse
Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Humanitas Research Hospital, Rozzano, Italy
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - May Abiad
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anne-Sophie Romijn
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Division of Trauma and Emergency Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Elaine P X van Ee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Leiden University Medical Center, Leiden, The Netherlands
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Abdallah M, Sunny S, Jimenez E, Ata S, Lee J, Episcopia B, Fornek M, Roudnitsky V, Quale J. Impact of Prophylactic Antibiotic Selection on the Prevention and Bacterial Flora of Surgical Site Infections After Colorectal Surgery. Surg Infect (Larchmt) 2023; 24:830-834. [PMID: 38015647 DOI: 10.1089/sur.2023.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
Background: Deep incisional and organ/space surgical site infections (SSIs) after colorectal surgery are associated with adverse outcomes. Multiple antibiotic regimens are recommended for peri-operative prophylaxis, with no particular regimen preferred over another. We compared the prophylaxis regimens used in patients with and without SSIs, and the impact of regimens on the flora involved in SSIs. Patients and Methods: Information was extracted from the National Healthcare Safety Network databank of patients undergoing colorectal surgery from 2015 to 2022 in a large public healthcare system in New York City. Patients with SSIs were identified, and controlling for nine variables, propensity score matching was used to create a matched control group without SSIs. Prophylactic regimens were compared between the matched groups with and without SSIs. Also, for the patients with SSIs, the impact of the prophylactic regimen on the subsequent pathogens involved the infection was examined. Results: A total of 275 patients with SSIs were compared to a matched cohort without SSIs. The prophylactic regimens were extremely similar between the SSI and control groups. Among the patients who developed SSIs, more patients who received cefoxitin had emergence of select cephalosporin-resistant Enterobacterales and Bacteroides spp. when compared with those who received β-lactam-β-lactamase inhibitors. Conclusions: The distribution of surgical prophylaxis regimens was remarkably similar between patients developing serious SSIs and a closely matched cohort that did not develop an SSI. However, given the downstream effects of more resistant and anaerobic flora should an infection develop, use of cefoxitin should be re-evaluated as a prophylactic agent.
Collapse
Affiliation(s)
- Marie Abdallah
- Department of Ambulatory Care, NYC Health+Hospitals/Kings County, Brooklyn, New York, USA
| | - Subin Sunny
- Department of Ambulatory Care, NYC Health+Hospitals/Kings County, Brooklyn, New York, USA
| | - Edwin Jimenez
- Department of Surgery, Division of Trauma, NYC Health+Hospitals/Kings County, Brooklyn, New York, USA
| | - Subhan Ata
- Department of Medicine, NYC Health+Hospitals/Kings County, Brooklyn, New York, USA
| | - Jennifer Lee
- Department of Ambulatory Care, NYC Health+Hospitals/Kings County, Brooklyn, New York, USA
| | - Briana Episcopia
- Department of Infection Prevention, NYC Health+Hospitals/Kings County, Brooklyn, New York, USA
| | - Mary Fornek
- Department of Infection Prevention, NYC Health+Hospitals/Central Office, New York, New York, USA
| | - Valery Roudnitsky
- Department of Surgery, Division of Trauma, NYC Health+Hospitals/Kings County, Brooklyn, New York, USA
| | - John Quale
- Department of Medicine, NYC Health+Hospitals/Kings County, Brooklyn, New York, USA
| |
Collapse
|
6
|
Yuval JB, Thompson HM, Verheij FS, Fiasconaro M, Patil S, Widmar M, Wei IH, Pappou EP, Smith JJ, Nash GM, Weiser MR, Paty PB, Garcia-Aguilar J. Comparison of Robotic, Laparoscopic, and Open Resections of Nonmetastatic Colon Cancer. Dis Colon Rectum 2023; 66:1347-1358. [PMID: 36649145 PMCID: PMC10369538 DOI: 10.1097/dcr.0000000000002637] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Laparoscopic resection for colon cancer has not been associated with improvements in oncological outcomes in comparison to open resection. Robotic resections are associated with increased lymph node yield and radicality of mesenteric resection in patients with right-sided tumors. It is unclear whether lymph node yield is higher in robotic resections in other parts of the colon and whether higher lymph node yield is associated with improved survival. OBJECTIVE To compare survival rates between robotic, laparoscopic, and open resections in a large cohort of patients with nonmetastatic colon cancer. DESIGN This is a retrospective observational study. SETTING A single comprehensive cancer center. PATIENTS Patients who underwent resection of nonmetastatic primary colon cancer between January 2006 and December 2018. MAIN OUTCOME MEASURES Univariable and multivariable models were used to identify predictors of disease-free and overall survival. Lymph node yield and perioperative outcomes were compared between operative approaches. RESULTS There were 2398 patients who met the inclusion criteria: 699 (29%) underwent open, 824 (34%) underwent laparoscopic, and 875 (36%) underwent robotic resection. The median follow-up was 3.8 years (45.4 months). Robotic surgery was associated with higher lymph node yield and radicality of mesenteric resection. On multivariable analysis, the surgical approach was not associated with a difference in disease-free or overall survival. Minimally invasive colectomy was associated with fewer complications and shorter length of stay in comparison to open surgery. In a direct comparison between the 2 minimally invasive approaches, robotic colectomy was associated with fewer complications, shorter length of stay, and lower conversion rate than laparoscopy. LIMITATIONS This was a single-center retrospective study. CONCLUSIONS Our data indicate that the 3 surgical approaches are similarly effective in treating primary resectable colon cancer and that differences in outcomes are observed primarily in the early postoperative period. See Video Abstract at http://links.lww.com/DCR/C115 . COMPARACIN DE RESECCIONES ROBTICAS, LAPAROSCPICAS Y ABIERTAS DE CNCER DE COLON NO METASTSICO ANTECEDENTES:La resección laparoscópica para el cáncer de colon no se ha asociado con mejoras en los resultados oncológicos en comparación con la resección abierta. Las resecciones robóticas se asocian con un mayor rendimiento de los ganglios linfáticos y la radicalidad de la resección mesentérica en pacientes con tumores del lado derecho. No está claro si la cosecha ganglionar es mayor en las resecciones robóticas en otras partes del colon y si un mayor rendimiento de los ganglios linfáticos se asocia con una mejor supervivencia.OBJETIVO:Comparar las tasas de supervivencia entre resecciones robóticas, laparoscópicas y abiertas en una gran cohorte de pacientes con cáncer de colon no metastásico.DISEÑO:Este es un estudio observacional retrospectivo.ESCENARIO:Este estudio se realizó en un único centro oncológico integral.PACIENTES:Pacientes que se sometieron a resección de cáncer de colon primario no metastásico entre enero de 2006 y diciembre de 2018.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizaron modelos univariables y multivariables para identificar predictores de supervivencia libre de enfermedad y global. La cosecha ganglionar y los resultados perioperatorios se compararon entre los abordajes quirúrgicos.RESULTADOS:Hubo 2398 pacientes que cumplieron con los criterios de inclusión: 699 (29%) se sometieron a cirugía abierta, 824 (34%) se sometieron a resección laparoscópica y 875 (36%) se sometieron a resección robótica. La mediana de seguimiento fue de 3,8 años (45,4 meses). La cirugía robótica se asoció con una mayor cosecha ganglionar y la radicalidad de la resección mesentérica. En el análisis multivariable, el abordaje quirúrgico no se asoció con una diferencia en la supervivencia general o libre de enfermedad. La colectomía mínimamente invasiva se asoció con menos complicaciones y una estancia más corta en comparación con la cirugía abierta. En una comparación directa entre los dos enfoques mínimamente invasivos, la colectomía robótica se asoció con menos complicaciones, una estancia más corta y una tasa de conversión más baja que la laparoscopia.LIMITACIONES:Este fue un estudio retrospectivo de un solo centro.CONCLUSIONES:Nuestros datos indican que los tres enfoques quirúrgicos son igualmente efectivos en el tratamiento del cáncer de colon resecable primario y que las diferencias en los resultados se observan principalmente en el período posoperatorio temprano. Consulte Video Resumen en http://links.lww.com/DCR/C115 . (Traducción-Dr. Felipe Bellolio ).
Collapse
Affiliation(s)
- Jonathan B. Yuval
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah M. Thompson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Floris S. Verheij
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Megan Fiasconaro
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iris H. Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emmanouil P. Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - J. Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Garrett M. Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip B. Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
7
|
Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Collapse
Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| |
Collapse
|
8
|
Levy BE, Wilt WS, Castle JT, McAtee E, Walling SC, Davenport DL, Bhakta A, Patel JA. Surgical Site Infections in Colorectal Resections: What is the Cost? J Surg Res 2023; 283:336-343. [PMID: 36427443 DOI: 10.1016/j.jss.2022.10.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/26/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Although surgical site infections (SSIs) associated with colectomy are tracked by the National Healthcare Safety Network/Center for Disease Control, untracked codes, mainly related to patients undergoing proctectomy, are not. These untracked codes are performed less often yet they may be at a greater risk of SSI due to their greater complexity. Determining the impact and predictors of SSI are critical in the development of quality improvement initiatives. METHODS Following an institutional review board approval, National Surgery Quality Improvement Program, institutional National Surgery Quality Improvement Program, and financial databases were queried for tracked colorectal resections and untracked colorectal resections (UCR). National data were obtained for January 2019-December 2019, and local procedures were identified between January 2013 and December 2019. Data were analyzed for preoperative SSI predictors, operative characteristics, outcomes, and 30-day postdischarge costs (30dPDC). RESULTS Nationally, 71,705 colorectal resections were identified, and institutionally, 2233 patients were identified. UCR accounted for 7.9% nationally and 11.8% of all colorectal resections institutionally. Tracked colorectal resection patients had a higher incidence of SSI predictors including sepsis, hypoalbuminemia, coagulopathy, hypertension, and American Society of Anesthesiologists class. UCR patients had a higher rate of SSIs [12.9% (P < 0.001), 15.2% (P = 0.064)], readmission, and unplanned return to the operating room. Index hospitalization and 30dPDC were significantly higher in patients experiencing an SSI. CONCLUSIONS SSI was associated with nearly a two-fold increase in index hospitalization costs and six-fold in 30dPDC. These data suggest opportunities to improve hospitalization costs and outcomes for patients undergoing UCR through protocols for SSI reduction and preventing readmissions.
Collapse
Affiliation(s)
- Brittany E Levy
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky.
| | - Wesley S Wilt
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jennifer T Castle
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Erin McAtee
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Samuel C Walling
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Daniel L Davenport
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Avinash Bhakta
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jitesh A Patel
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| |
Collapse
|
9
|
Abstract
IMPORTANCE Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer. OBSERVATIONS Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis. CONCLUSIONS AND RELEVANCE Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol-based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.
Collapse
Affiliation(s)
- Jessica L Seidelman
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Christopher R Mantyh
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
10
|
Sharon CE, Grinberg S, Straker RJ, Mahmoud NN, Kelz RR, Miura JT, Karakousis GC. Trends in infectious complications after partial colectomy for colon cancer over a decade: A national cohort study. Surgery 2022; 172:1622-1628. [PMID: 36655827 DOI: 10.1016/j.surg.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/09/2022] [Accepted: 09/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program helps participating hospitals track and report surgical complications with the goal of improving patient care. We sought to determine whether postoperative infectious complications after elective colectomy for malignancy improved among participating centers over time. METHODS Patients with colon malignancies who underwent elective partial colectomy with primary anastomosis (categorized as low or non-low) were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2011-2019). Thirty-day postoperative infectious complications analyzed by year included superficial, deep, and organ space surgical site infections, urinary tract infection, pneumonia, and sepsis. Trends in patient and treatment characteristics were investigated using log-linear regression along with their association with infectious outcomes. RESULTS Of the 78,827 patients identified, 51% were female, and the median age was 68. The majority (84%) underwent partial colectomy without a low anastomosis. There was a decrease in all infectious complications except for organ space infections which increased 35% overall from 2.0 to 2.7% (P = .037), driven by patients without a low anastomosis (1.9%-2.7%, P = .01). There was no change in most patient factors associated with organ space infections, except for a notable increase in American Society of Anesthesiologists class III and IV-V patients over time, both associated with organ space infections (P < .001; P = .002). CONCLUSION Infectious complications have decreased significantly overall after colectomy for colon cancer, whereas there has been an increase in organ space infection rates specifically. Although changing patient characteristics may contribute to this observed trend, further study is needed to better understand its etiology to help mitigate this complication.
Collapse
Affiliation(s)
- Cimarron E Sharon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Samuel Grinberg
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Richard J Straker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Najjia N Mahmoud
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John T Miura
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. https://twitter.com/pennsurgery
| |
Collapse
|
11
|
Jalalzadeh H, Wolfhagen N, Harmsen WJ, Griekspoor M, Boermeester MA. A Network Meta-Analysis and GRADE Assessment of the Effect of Preoperative Oral Antibiotics with and Without Mechanical Bowel Preparation on Surgical Site Infection Rate in Colorectal Surgery. ANNALS OF SURGERY OPEN 2022; 3:e175. [PMID: 37601145 PMCID: PMC10431570 DOI: 10.1097/as9.0000000000000175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/09/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To compare the effect of different methods of bowel preparation on the incidence of surgical site infections (SSI), anastomotic leakage (AL), and mortality in patients undergoing elective colorectal surgery. Background Recent guidelines advise mechanical bowel preparation with oral antibiotics (MBP-OA) for the prevention of SSI in colorectal surgery. Recent trials suggest oral antibiotics (OA) alone may be sufficient. Methods PubMed, MEDLINE, and Embase were searched from inception until 10-08-2021. We included randomized controlled trials (RCTs) comparing multiple methods of bowel preparation (mechanical bowel preparation [MBP], OA, MBP-OA, or no preparation) with regards to clinical outcomes such as incidence of SSI, AL, and mortality rates. A frequentist random-effects network meta-analysis was conducted to estimate the network effects of the different treatment options. Results We included 48 studies with 13,611 patients. Compared to no preparation, combined direct and indirect network estimates showed a relative risk (RR) for SSI of 0.57 (95% confidence interval [CI], 0.45-0.72) for MBP-OA, 0.68 (95% CI, 0.49-0.95) for OA, and 1.05 (95% CI, 0.87-1.26) for MBP. The RR for MBP-OA compared to OA was 0.84 (95% CI, 0.60-1.19); in sensitivity analysis of mainly laparoscopic procedures this effect of MBP-OA was more profound (RR, 0.56; 95% CI, 0.31-0.99). Conclusions This network meta-analysis of RCTs finds that both mechanical bowel preparation with oral antibiotics and oral antibiotics alone are comparably effective in the prevention of SSI. The evidence is uncertain about the relative benefit of MBP-OA compared to OA alone. Therefore, it seems justified to use either of the 2 for the prevention of SSI in colorectal surgery.
Collapse
Affiliation(s)
- Hasti Jalalzadeh
- From the Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, The Netherlands
| | - Niels Wolfhagen
- From the Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, The Netherlands
| | | | | | - Marja A. Boermeester
- From the Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, The Netherlands
| |
Collapse
|
12
|
Schlick CJR, Huang R, Brajcich BC, Halverson AL, Yang AD, Kreutzer L, Bilimoria KY, McGee MF. Unbundling Bundles: Evaluating the Association of Individual Colorectal Surgical Site Infection Reduction Bundle Elements on Infection Rates in a Statewide Collaborative. Dis Colon Rectum 2022; 65:1052-1061. [PMID: 34840291 PMCID: PMC9124224 DOI: 10.1097/dcr.0000000000002223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical site infection reduction bundles are effective but can be complex and resource intensive. Understanding which bundle elements are associated with reduced surgical site infections may guide concise bundle implementation. OBJECTIVE The purpose of this study was to evaluate the association of individual surgical site infection reduction bundle elements with infection rates. DESIGN This was a post-hoc analysis of a prospective cohort study. SETTING This study took place at Illinois Surgical Quality Improvement Collaborative hospitals. PATIENTS Patients who had elective colorectal resections at participating hospitals from 2016 to 2017. INTERVENTIONS The intervention was a 16-element colorectal surgical site infection reduction bundle. MAIN OUTCOME MEASURES Surgical site infection rates were compared among patients by adherence with each bundle element using χ 2 tests and multivariable logistic regression. Principal component analysis identified composites of correlated bundle elements. Coincidence analysis identified combinations of bundle elements or principal component composites associated with the absence of surgical site infection. RESULTS Among 2722 patients, 192 (7.1%) developed a surgical site infection. Infections were less likely when oral antibiotics (OR 0.63 [95% CI 0.41-0.97]), wound protectors (OR 0.55 [95% CI 0.37-0.81]), and occlusive dressings (OR 0.71 [95% CI 0.51-1.00]) were used. Bundle elements were reduced into 5 principal component composites. Adherence with the combination of oral antibiotics, wound protector, or redosing intravenous antibiotic prophylaxis plus chlorhexidine-alcohol intraoperative skin preparation was associated with the absence of infection (consistency = 0.94, coverage = 0.96). Four of the 5 principal component composites in various combinations were associated with the absence of surgical site infection, whereas the composite consisting of occlusive dressing placement, postoperative dressing removal, and daily postoperative chlorhexidine incisional cleansing had no association with the outcome. LIMITATIONS The inclusion of hospitals engaged in quality improvement initiatives may limit the generalizability of these data. CONCLUSION Bundle elements had varying association with infection reduction. Implementation of colorectal surgical site infection reduction bundles should focus on the specific elements associated with low surgical site infections. See Video Abstract at http://links.lww.com/DCR/B808 . DESEMPAQUETANDO PAQUETES EVALUACIN DE LA ASOCIACIN DE ELEMENTOS INDIVIDUALES DEL PAQUETE DE REDUCCIN DE INFECCIONES DEL SITIO QUIRRGICO COLORRECTAL CON LAS TASAS DE INFECCIN EN UNA COLABORACIN ESTATAL ANTECEDENTES:Los paquetes de reducción de infecciones del sitio quirúrgico son efectivos pero pueden ser complejos y requieren muchos recursos. Comprender qué elementos del paquete están asociados con la reducción de las infecciones del sitio quirúrgico puede guiar la implementación concisa del paquete.OBJETIVO:Evaluar la asociación de los elementos individuales del paquete de reducción de infecciones del sitio quirúrgico con las tasas de infección.DISEÑO:Análisis post-hoc de un estudio de cohorte prospectivo.ESCENARIO:Hospitales colaborativos para la mejora de la calidad quirúrgica de Illinois.PACIENTES:Resecciones colorrectales electivas en los hospitales participantes entre 2016 y 2017.INTERVENCIONES:Paquete de reducción de infección del sitio quirúrgico colorrectal de 16 elementos.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las tasas de infección del sitio quirúrgico entre los pacientes según la adherencia con cada elemento del paquete mediante pruebas de Chi cuadrado y regresión logística multivariable. El análisis de componentes principales identificó compuestos de elementos de paquete correlacionados. El análisis de coincidencia identificó combinaciones de elementos del haz o compuestos de componentes principales asociados con la ausencia de infección del sitio quirúrgico.RESULTADOS:Entre 2722 pacientes, 192 (7,1%) desarrollaron una infección del sitio quirúrgico. Las infecciones fueron menos probables cuando se administraron antibióticos orales (OR 0,63 (IC 95% 0,41-0,97)), protectores de heridas (OR 0,55 (IC 95% 0,37-0,81)) y vendajes oclusivos (OR 0.71 (IC 95% 0,51-1,00]) fueron usados. Los elementos del paquete se redujeron a 5 grupos de componentes principales. La adherencia a la combinación de (1) antibióticos orales, (2) protector de heridas o (3) redosificación de profilaxis antibiótica intravenosa más preparación de la piel intraoperatoria con clorhexidina-alcohol se asoció con la ausencia de infección (consistencia = 0,94, cobertura = 0,96). Cuatro de los cinco grupos de componentes principales en varias combinaciones se asociaron con la ausencia de infección del sitio quirúrgico, mientras que el grupo que consiste en la colocación del apósito oclusivo, la remosión del apósito en posoperatorio y la limpieza incisional posoperatoria diaria con clorhexidina no tuvo asociación con el resultado.LIMITACIONES:La inclusión de hospitales que participan en iniciativas de mejora de la calidad puede limitar la generalización de estos datos.CONCLUSIONES:Los elementos del paquete tuvieron una asociación variable con la reducción de la infección. La implementación de paquetes de reducción de infecciones del sitio quirúrgico colorrectal debe centrarse en los elementos específicos asociados con pocas infecciones del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B808 . (Traducción-Juan Carlos Reyes ).
Collapse
Affiliation(s)
- Cary Jo R. Schlick
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Reiping Huang
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Brian C. Brajcich
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Amy L. Halverson
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Anthony D. Yang
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Lindsey Kreutzer
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Karl Y. Bilimoria
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
- Center for Healthcare Studies, Institute for Public Health
and Medicine, Feinberg School of Medicine, Northwestern University, Chicago,
Illinois
| | - Michael F. McGee
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| |
Collapse
|
13
|
Raslan R, Doll M, Albert H, Shah H, Bohl J, Cooper K, Stevens MP, Bearman G. Staphylococcal decolonization to prevent surgical site infection: Is there a role in colorectal surgery? ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e116. [PMID: 36483388 PMCID: PMC9726530 DOI: 10.1017/ash.2022.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We implemented a preoperative staphylococcal decolonization protocol for colorectal surgeries if efforts to further reduce surgical site infections (SSIs). DESIGN Retrospective observational study. SETTING Tertiary-care, academic medical center. PATIENTS Adult patients who underwent colorectal surgery, as defined by National Healthcare Safety Network (NHSN), between July 2015 and June 2020. Emergent cases were excluded. METHODS Simple and multivariable logistic regression were performed to evaluate the relationship between decolonization and subsequent SSI. Other predictive variables included age, sex, body mass index, procedure duration, American Society of Anesthesiology (ASA) score, diabetes, smoking, and surgical oncology service. RESULTS In total, 1,683 patients underwent nonemergent NHSN-defined colorectal surgery, and 33.7% underwent the staphylococcal decolonization protocol. SSI occurred in 92 (5.5%); 53 were organ-space infections and 39 were superficial wound infections. We detected no difference in overall SSIs between those decolonized and not decolonized (P = .17). However, superficial wound infections were reduced in the group that received decolonization versus those that did not: 7 (1.2%) of 568 versus 32 (2.9%) of 1,115 (P = .04). CONCLUSIONS Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.
Collapse
Affiliation(s)
- Rasha Raslan
- Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Michelle Doll
- Virginia Commonwealth University Medical Center, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Heather Albert
- Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Hirsh Shah
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Jaime Bohl
- Virginia Commonwealth University Medical Center, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Kaila Cooper
- Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Michael P. Stevens
- Virginia Commonwealth University Medical Center, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Gonzalo Bearman
- Virginia Commonwealth University Medical Center, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| |
Collapse
|
14
|
Bogner A, Stracke M, Bork U, Wolk S, Pecqueux M, Kaden S, Distler M, Kahlert C, Weitz J, Welsch T, Fritzmann J. Selective decontamination of the digestive tract in colorectal surgery reduces anastomotic leakage and costs: a propensity score analysis. Langenbecks Arch Surg 2022; 407:2441-2452. [PMID: 35551468 PMCID: PMC9468075 DOI: 10.1007/s00423-022-02540-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/29/2022] [Indexed: 11/30/2022]
Abstract
Purpose Anastomotic leakage (AL) and surgical site infection (SSI) account for most postoperative complications in colorectal surgery. The aim of this retrospective trial was to investigate whether perioperative selective decontamination of the digestive tract (SDD) reduces these complications and to provide a cost-effectiveness model for elective colorectal surgery. Methods All patients operated between November 2016 and March 2020 were included in our analysis. Patients in the primary cohort (PC) received SDD and those in the historical control cohort (CC) did not receive SDD. In the case of rectal/sigmoid resection, SDD was also applied via a transanally placed Foley catheter (TAFC) for 48 h postoperatively. A propensity score-matched analysis was performed to identify risk factors for AL and SSI. Costs were calculated based on German diagnosis-related group (DRG) fees per case. Results A total of 308 patients (154 per cohort) with a median age of 62.6 years (IQR 52.5–70.8) were analyzed. AL was observed in ten patients (6.5%) in the PC and 23 patients (14.9%) in the CC (OR 0.380, 95% CI 0.174–0.833; P = 0.016). SSI occurred in 14 patients (9.1%) in the PC and 30 patients in the CC (19.5%), representing a significant reduction in our SSI rate (P = 0.009). The cost-effectiveness analysis showed that SDD is highly effective in saving costs with a number needed to treat of 12 for AL and 10 for SSI. Conclusion SDD significantly reduces the incidence of AL and SSI and saves costs for the general healthcare system. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-022-02540-6.
Collapse
Affiliation(s)
- Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany. .,German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany. .,Department of Gastrointestinal, Thoracic and Vascular Surgery, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Maximilian Stracke
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Ulrich Bork
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Mathieu Pecqueux
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Sandra Kaden
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany.,Clinical Pharmacy, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Thilo Welsch
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany.,Department of General, Visceral and Thoracic Surgery, Oberschwabenklinik Ravensburg, Ravensburg, Germany
| | - Johannes Fritzmann
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| |
Collapse
|
15
|
Brajcich BC, Schlick CJR, Halverson AL, Huang R, Yang AD, Love R, Bilimoria KY, McGee MF. Association between Patient and Hospital Characteristics and Adherence to a Surgical Site Infection Reduction Bundle in a Statewide Surgical Quality Improvement Collaborative. J Am Coll Surg 2022; 234:783-792. [PMID: 35426391 DOI: 10.1097/xcs.0000000000000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adherence to bundled interventions can reduce surgical site infection (SSI) rates; however, predictors of successful implementation are poorly characterized. We studied the association of patient and hospital characteristics with adherence to a colorectal SSI reduction bundle across a statewide surgical collaborative. STUDY DESIGN A 16-component colorectal SSI reduction bundle was introduced in 2016 across a statewide quality improvement collaborative. Bundle adherence was measured for patients who underwent colorectal operations at participating institutions. Multivariable mixed-effects logistic regression models were constructed to estimate associations of patient and hospital factors with bundle adherence and quantify sources of variation. RESULTS Among 2,403 patients at 35 hospitals, a median of 11 of 16 (68.8%, interquartile range 8 to 13) bundle elements were completed. The likelihood of completing 11 or more elements was increased for obese patients (56.8% vs 51.5%, odds ratio [OR] 1.39, 95% CI 1.05 to 1.86, p = 0.022) but reduced for underweight patients (31.0% vs 51.5%, OR 0.51, 95% CI 0.26 to 1.00, p = 0.048) compared with patients with a normal BMI. Lower adherence was noted for patients treated at safety net hospitals (n = 9 hospitals, 24.4% vs 54.4%, OR 0.08, 95% CI 0.01 to 0.44, p = 0.004). The largest proportion of adherence variation was attributable to hospital factors for six bundle elements, surgeon factors for no elements, and patient factors for nine elements. CONCLUSION Adherence to an SSI reduction bundle is associated with patient BMI and hospital safety net status. Quality improvement groups should consider institutional traits for optimal implementation of SSI bundles. Safety net hospitals may require additional focus to overcome unique implementation barriers.
Collapse
Affiliation(s)
- Brian C Brajcich
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Cary Jo R Schlick
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Amy L Halverson
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Reiping Huang
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Anthony D Yang
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Remi Love
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Karl Y Bilimoria
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Michael F McGee
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| |
Collapse
|
16
|
Rumer KK, Hedou J, Tsai A, Einhaus J, Verdonk F, Stanley N, Choisy B, Ganio E, Bonham A, Jacobsen D, Warrington B, Gao X, Tingle M, McAllister TN, Fallahzadeh R, Feyaerts D, Stelzer I, Gaudilliere D, Ando K, Shelton A, Morris A, Kebebew E, Aghaeepour N, Kin C, Angst MS, Gaudilliere B. Integrated Single-cell and Plasma Proteomic Modeling to Predict Surgical Site Complications: A Prospective Cohort Study. Ann Surg 2022; 275:582-590. [PMID: 34954754 PMCID: PMC8816871 DOI: 10.1097/sla.0000000000005348] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether single-cell and plasma proteomic elements of the host's immune response to surgery accurately identify patients who develop a surgical site complication (SSC) after major abdominal surgery. SUMMARY BACKGROUND DATA SSCs may occur in up to 25% of patients undergoing bowel resection, resulting in significant morbidity and economic burden. However, the accurate prediction of SSCs remains clinically challenging. Leveraging high-content proteomic technologies to comprehensively profile patients' immune response to surgery is a promising approach to identify predictive biological factors of SSCs. METHODS Forty-one patients undergoing non-cancer bowel resection were prospectively enrolled. Blood samples collected before surgery and on postoperative day one (POD1) were analyzed using a combination of single-cell mass cytometry and plasma proteomics. The primary outcome was the occurrence of an SSC, including surgical site infection, anastomotic leak, or wound dehiscence within 30 days of surgery. RESULTS A multiomic model integrating the single-cell and plasma proteomic data collected on POD1 accurately differentiated patients with (n = 11) and without (n = 30) an SSC [area under the curve (AUC) = 0.86]. Model features included coregulated proinflammatory (eg, IL-6- and MyD88- signaling responses in myeloid cells) and immunosuppressive (eg, JAK/STAT signaling responses in M-MDSCs and Tregs) events preceding an SSC. Importantly, analysis of the immunological data obtained before surgery also yielded a model accurately predicting SSCs (AUC = 0.82). CONCLUSIONS The multiomic analysis of patients' immune response after surgery and immune state before surgery revealed systemic immune signatures preceding the development of SSCs. Our results suggest that integrating immunological data in perioperative risk assessment paradigms is a plausible strategy to guide individualized clinical care.
Collapse
Affiliation(s)
- Kristen K. Rumer
- Division of General Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Julien Hedou
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Amy Tsai
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Jakob Einhaus
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University of Tuebingen, Tuebingen, Germany
| | - Franck Verdonk
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, France
| | - Natalie Stanley
- Department of Computer Science and Computational Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Benjamin Choisy
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Edward Ganio
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Adam Bonham
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Danielle Jacobsen
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Beata Warrington
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Xiaoxiao Gao
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Martha Tingle
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Tiffany N. McAllister
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Ramin Fallahzadeh
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Dorien Feyaerts
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Ina Stelzer
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Dyani Gaudilliere
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Kazuo Ando
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Andrew Shelton
- Division of General Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Arden Morris
- Division of General Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Electron Kebebew
- Division of General Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
- Department of Biomedical Data Sciences, Stanford University, Stanford, CA
- Department of Pediatrics, Stanford University, Stanford, CA
| | - Cindy Kin
- Division of General Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Martin S. Angst
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Brice Gaudilliere
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
- Department of Pediatrics, Stanford University, Stanford, CA
| |
Collapse
|
17
|
Graham LA, Wagner TH, Sambare TD, Hawn MT. Timing and Cost of Wound Complications After Colorectal Resection. Dis Colon Rectum 2021; 64:1551-1558. [PMID: 34747918 DOI: 10.1097/dcr.0000000000002065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING This study was conducted at a Veterans Affairs medical center. SETTING Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL ANTECEDENTES:Más del 50% de complicaciones postoperatorias de la herida ocurren después del alta. Es la complicación postoperatoria más común y el motivo más frecuente de reingreso después del procedimiento quirúrgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida después del alta quirúrgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las características de las complicaciones de la herida, identificadas después del alta hospitalaria, en pacientes sometidos a cirugía colorrectal, en comparación con las complicaciones intrahospitalarias.DISEÑO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirúrgica de la Administración de Salud de Veteranos.ENTORNO CLÍNICO:Administración de Veteranos.PACIENTES:Pacientes sometidos a resección colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACIÓN:Costos de atención ajustados al alta, 30 días y 90 días después de la cirugía.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicación de la herida dentro de los 30 días de la cirugía. (49,2% índice hospitalario, 50,8% después del alta). En comparación con los pacientes, del índice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), más infecciones de órganos/espacios quirúrgicos (14,3% frente a 10,1%, p <0,01), tasas más altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberían de haber tenido un abordaje laparoscópico para su cirugía (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugía a los 30 días, fue de $ 37,315 (desviación estándar = $ 29,319). En comparación con el índice de complicaciones de las herida hospitalaria, las complicaciones de la herida después del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 días y $ 9,736 (15%, p<0,001) y menor costo a los 90 días. Los pacientes con índice de complicación de la herida hospitalaria, tenían un 40% menos de probabilidades de requerir reingreso a los 30 días, pero sus reingresos eran $ 12,518 más costosos que los reingresos entre los pacientes presentando complicación de la herida recién identificada después del alta (p <0,001).LIMITACIONES:Limitado a las características del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 días, que aquellos con complicaciones de la herida identificadas durante su índice de hospitalización y aproximadamente la mitad fueron tratados de forma ambulatoria.
Collapse
Affiliation(s)
- Laura A Graham
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Todd H Wagner
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Tanmaya D Sambare
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Mary T Hawn
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| |
Collapse
|
18
|
Evaluation of the costing methodology of published studies estimating costs of surgical site infections: A systematic review. Infect Control Hosp Epidemiol 2021; 43:898-914. [PMID: 34551830 DOI: 10.1017/ice.2021.381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Surgical site infections (SSIs) are associated with increased length of hospitalization and costs. Epidemiologists and infection control practitioners, who are in charge of implementing infection control measures, have to assess the quality and relevance of the published SSI cost estimates before using them to support their decisions. In this review, we aimed to determine the distribution and trend of analytical methodologies used to estimate cost of SSIs, to evaluate the quality of costing methods and the transparency of cost estimates, and to assess whether researchers were more inclined to use transferable studies. METHODS We searched MEDLINE to identify published studies that estimated costs of SSIs from 2007 to March 2021, determined the analytical methodologies, and evaluated transferability of studies based on 2 evaluation axes. We compared the number of citations by transferability axes. RESULTS We included 70 studies in our review. Matching and regression analysis represented 83% of analytical methodologies used without change over time. Most studies adopted a hospital perspective, included inpatient costs, and excluded postdischarge costs (borne by patients, caregivers, and community health services). Few studies had high transferability. Studies with high transferability levels were more likely to be cited. CONCLUSIONS Most of the studies used methodologies that control for confounding factors to minimize bias. After the article by Fukuda et al, there was no significant improvement in the transferability of published studies; however, transferable studies became more likely to be cited, indicating increased awareness about fundamentals in costing methodologies.
Collapse
|
19
|
Pollack E, Johnston S, Petraiuolo WJ, Roy S, Galvain T. Economic Analysis of Leak Complications in Anastomoses Performed with Powered versus Manual Circular Staplers in Left-Sided Colorectal Resections: A US-Based Cost Analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:531-540. [PMID: 34168470 PMCID: PMC8217739 DOI: 10.2147/ceor.s305296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/10/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose To estimate the cost impact of using the ECHELON CIRCULAR™ Powered Stapler (ECP) compared with manual circular staplers (standard of care, SOC) among patients undergoing colectomy procedures that involve left-sided anastomosis. Methods A US hospital-based budget impact model was developed to estimate the impact of ECP in reducing the surgical complication of anastomotic leak. The incremental acquisition cost of ECP vs SOC was compared to the net potential savings from reduced complication costs. The model was based on complication rates from a recently published matching-adjusted indirect comparison (MAIC) that compared clinical and healthcare utilization outcomes of patients using ECP with those of a propensity score-matched retrospective SOC control cohort from a real-world clinical practice population. The model assessed total cost, average length of stay (LOS), proportion of patients with a non-home discharge, and all-cause readmission. Deterministic (DSA) and probabilistic sensitivity analyses (PSA) were conducted to evaluate the robustness of the model assumptions and inputs. Results Despite a higher device cost of $412 for ECP compared with $298 for a manual stapler, annual savings due to avoided complications with ECP was $53,987 for anastomotic leak, assuming 100 procedures per year with each type of circular stapler. ECP also helped to avoid 27 LOS days, 0.38 readmissions and 0.22 non-home discharges. Sensitivity analyses around potential drivers of costs established the robustness of economic savings with the use of ECP - with annual savings being most impacted by the probability of anastomotic leak complication in the DSA. Conclusion This model demonstrates that among patients undergoing left-sided colectomy procedures, the incremental cost of using the ECHELON CIRCULAR™ Powered Stapler instead of a manual circular stapler was offset by the savings from lowered incidence and cost of management of anastomotic leaks in the hospital setting.
Collapse
Affiliation(s)
- Esther Pollack
- Franchise Health Economics and Market Access, Ethicon, Blue Ash, OH, USA
| | - Stephen Johnston
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | | | - Sanjoy Roy
- Franchise Health Economics and Market Access, Ethicon, Blue Ash, OH, USA
| | - Thibaut Galvain
- Global Health Economics, Johnson and Johnson Medical Devices, New Brunswick, NJ, USA
| |
Collapse
|
20
|
Nguyen SH, Defnet AM, Pati BA, Russell DM, Gillern SM, Lin E, Sullivan PS, Yheulon C. Role of Negative Pressure Wound Therapy When Performing Elective Open Colectomy. Surg Infect (Larchmt) 2020; 22:562-567. [PMID: 33232647 DOI: 10.1089/sur.2020.183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The impact of negative pressure wound therapy (NPWT) as an adjunct to colorectal surgery is largely unknown. The purpose of this study was to determine whether NPWT impacts wound complications during elective open colectomy. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and colectomy targeted procedure databases were queried from 2012-2018 for patients undergoing non-emergent planned open colectomies. Groups were propensity score matched for anastomosis type (ileo-colic, colo-colic, colo-rectal), age, body mass index (BMI), diabetes, smoking, steroid use, wound classification, American Society of Anesthesiologists (ASA) class, operative time, and wound layers closed. Wound complications were defined as superficial surgical site infection (SSI), deep incisional SSI, and dehiscence. Results: A total of 15,770 patients were identified; 92 underwent simultaneous NPWT (0.58%). Non-NPWT patients were matched at a 5:1 ratio, producing 460 comparisons. There was no difference in wound complications (8.26% non-NPWT vs. 6.52% NPWT; p = 0.574). In addition, there were no differences in wound complications when only including patients who had NPWT placed over closed skin (9.11% non-NPWT vs. 7.25% NPWT; p = 0.789). On multivariable analysis, NPWT was not associated with wound complications (odds ratio [OR] 0.79; 95% confidence interval [CI], 0.37-1.69). Conclusions: Negative pressure wound therapy does not reduce wound complications in open elective colectomies. Large randomized studies and more granular data are needed to ascertain if there is any benefit in select patient populations.
Collapse
Affiliation(s)
- Scott H Nguyen
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Ann M Defnet
- Division of GI and General Surgery, Emory University, Emory University, Atlanta, Georgia, USA
| | - Brooke A Pati
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Dylan M Russell
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Suzanne M Gillern
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Edward Lin
- Division of GI and General Surgery, Emory University, Emory University, Atlanta, Georgia, USA
| | | | - Christopher Yheulon
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA.,Division of GI and General Surgery, Emory University, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
21
|
Early Discontinuation of Breast Free Flap Monitoring: A Strategy Driven by National Data. Plast Reconstr Surg 2020; 146:258e-264e. [PMID: 32842096 DOI: 10.1097/prs.0000000000007052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multiple single-institution studies have revealed that breast free flap compromise usually occurs within the first 48 postoperative hours. However, national studies analyzing the rates and timing of breast free flap compromise are lacking. This study aimed to fill this gap in knowledge to better guide postoperative monitoring. METHODS All women undergoing breast free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2016 database were analyzed to determine the rates and timing of free flap take-back. Take-backs were stratified by postoperative day through the first month. Multivariable modified Poisson regression analysis was used to determine the independent predictors of free flap take-back. RESULTS A total of 6792 breast free flap patients were analyzed. Multivariable analysis revealed that body mass index of 40 kg/m or higher, hypertension, American Society of Anesthesiologists class of 3 or higher, steroid use, and smoking were independent predictors of take-back (p < 0.05). Take-back occurred at the highest rate during postoperative day 1, dropped significantly by postoperative day 2 (p < 0.001), and remained consistently low after postoperative day 2 (<0.6 percent daily). The identified risk factors significantly increased the likelihood of take-back on postoperative day 1 (p < 0.05), with a trend noted on postoperative day 2 (p = 0.06). Fewer than 0.4 percent of patients (n = 27) underwent take-back on postoperative day 2 without having risk factors. CONCLUSIONS This is the first national study specifically analyzing rates, timing, and independent predictors of breast free flap take-back. The data support discontinuing breast free flap monitoring by the end of postoperative day 1 for patients without risk factors, given the very low rate of take-back for such patients during postoperative day 2 (≤0.4 percent). CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
Collapse
|
22
|
Hajirawala LN, Legare TB, Tiu SPT, DeKerlegand AM, Barton JS, Davis KG, Orangio GR. The Impact of a Colorectal Care Bundle for Surgical Site Infections at an Academic Disproportionate Share Hospital With a Level I Trauma Center. Am Surg 2020; 86:848-855. [PMID: 32726131 DOI: 10.1177/0003134820940240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Colorectal care bundles for surgical site infections (CRCB-SSIs) have been shown to reduce SSIs following elective colorectal surgery (CRS). There are limited data evaluating the effect of CRCB-SSI at Academic Disproportionate Share Hospitals (ADSH) with significant rates of urgent and emergent cases. METHODS A CRCB-SSI was implemented in April 2016. We reviewed medical records of all patients undergoing colon resections between August 2015 and December 2017. Patients were divided into preimplementation and postimplementation groups. The primary endpoint was the SSI rate, and the secondary endpoint included types of SSI (superficial, deep, organ space). Univariable and multivariable analyses were performed. A subset analysis was performed in elective cases. RESULTS We analyzed a total of 417 patients. Of these, 116 (28%) and 301 (72%) patients were in the preimplementation and postimplementation groups, respectively. The rate of SSI decreased from 30.1% to 15.9% in the postimplementation group (P = .0012); however, it was not statistically significant after adjusting for baseline differences (relative risk [RR] 0.65; 95% CI 0.41-1.02).The elective subset included 219 patients. The rate of SSI in this cohort decreased from 25% to 10.5% in the postimplementation group (P = .0012) and remained significant following multivariable analysis (RR 0.41, 95% CI 0.19- 0.88). There were no differences in the subtypes of SSI. DISCUSSION While the CRCB-SSI was effective in decreasing the postoperative SSI rate for elective cases, its effect on the overall patient population was limited. CRCB-SSIs are not enough to bring SSI rates to accepted rates in high-risk patients such as those seen at ADSH.
Collapse
Affiliation(s)
- Luv N Hajirawala
- 12258 Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Timothy B Legare
- 12258 Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Simon Peter T Tiu
- 12258 Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Amy M DeKerlegand
- 12258 Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Jeffrey S Barton
- Section of Colorectal Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Kurt G Davis
- Section of Colorectal Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Guy R Orangio
- Section of Colorectal Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| |
Collapse
|
23
|
Apte SS, Moloo H, Jeong A, Liu M, Vandemeer L, Suh K, Thavorn K, Fergusson DA, Clemons M, Auer RC. Prospective randomised controlled trial using the REthinking Clinical Trials (REaCT) platform and National Surgical Quality Improvement Program (NSQIP) to compare no preparation versus preoperative oral antibiotics alone for surgical site infection rates in elective colon surgery: a protocol. BMJ Open 2020; 10:e036866. [PMID: 32647023 PMCID: PMC7351286 DOI: 10.1136/bmjopen-2020-036866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/24/2020] [Accepted: 06/02/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Despite 40 randomised controlled trials (RCTs) investigating preoperative oral antibiotics (OA) and mechanical bowel preparation (MBP) to reduce surgical site infection (SSI) rate following colon surgery, there has never been an RCT published comparing OA alone versus no preparation. Of the four possible regimens (OA alone, MBP alone, OA plus MBP and no preparation), randomised evidence is conflicting for studied groups. Furthermore, guidelines vary, with recommendations for OA alone, OA plus MBP or no preparation. The National Surgical Quality Improvement Program (NSQIP) has automated data collection for surgical patients. Similarly, the 'REthinking Clinical Trials' (REaCT) platform increases RCT enrolment by simplifying pragmatic trial design. In this novel RCT protocol, we combine REaCT and NSQIP to compare OA alone versus no preparation for SSI rate reduction in elective colon surgery. To our knowledge, this is the first published RCT protocol that leverages NSQIP for data collection. In our feasibility study, 67 of 74 eligible patients (90%) were enrolled and 63 of 67 (94%) were adherent to protocol. The 'REaCT-NSQIP' trial design has great potential to efficiently generate level I evidence for other perioperative interventions. METHODS AND ANALYSIS SSI rates following elective colorectal surgery after preoperative OA or no preparation will be compared. We predict 45% relative rate reduction of SSI, improvement in length of stay, reduced costs and increased quality of life, with similar antibiotic-related complications. Consent, using the 'integrated consent model', and randomisation on a mobile device are completed by the surgeon in a single clinical encounter. Data collection for the primary end point is automatic through NSQIP. Analysis of cost per weighted case, cost utility and quality-adjusted life years will be done. ETHICS AND DISSEMINATION This study is approved by The Ontario Cancer Research Ethics Board. Results will be disseminated in surgical conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03663504; Pre-results, recruitment phase.
Collapse
Affiliation(s)
- Sameer S Apte
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Husein Moloo
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ahwon Jeong
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michelle Liu
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lisa Vandemeer
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kathryn Suh
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mark Clemons
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rebecca C Auer
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
24
|
Lawler J, Choynowski M, Bailey K, Bucholc M, Johnston A, Sugrue M. Meta-analysis of the impact of postoperative infective complications on oncological outcomes in colorectal cancer surgery. BJS Open 2020; 4:737-747. [PMID: 32525280 PMCID: PMC7528523 DOI: 10.1002/bjs5.50302] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/26/2020] [Accepted: 05/02/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cancer outcomes are complex, involving prevention, early detection and optimal multidisciplinary care. Postoperative infection and surgical site-infection (SSI) are not only uncomfortable for patients and costly, but may also be associated with poor oncological outcomes. A meta-analysis was undertaken to assess the oncological effects of SSI in patients with colorectal cancer. METHODS An ethically approved PROSPERO-registered meta-analysis was conducted following PRISMA guidelines. PubMed and Scopus databases were searched for studies published between 2007 and 2017 reporting the effects of postoperative infective complications on oncological survival in colorectal cancer. Results were separated into those for SSI and those concerning anastomotic leakage. Articles with a Methodological Index for Non-Randomized Studies score of at least 18 were included. Hazard ratios (HRs) with 95 per cent confidence intervals were computed for risk factors using an observed to expected and variance fixed-effect model. RESULTS Of 5027 articles were reviewed, 43 met the inclusion criteria, with a total of 154 981 patients. Infective complications had significant negative effects on overall survival (HR 1·37, 95 per cent c.i. 1·28 to 1·46) and cancer-specific survival (HR 2·58, 2·15 to 3·10). Anastomotic leakage occurred in 7·4 per cent and had a significant negative impact on disease-free survival (HR 1·14, 1·09 to 1·20), overall survival (HR 1·34, 1·28 to 1·39), cancer-specific survival (HR 1·43, 1·31 to 1·55), local recurrence (HR 1·18, 1·06 to 1·32) and overall recurrence (HR 1·46, 1·27 to 1·68). CONCLUSION This meta-analysis identified a significant negative impact of postoperative infective complications on overall and cancer-specific survival in patients undergoing colorectal surgery.
Collapse
Affiliation(s)
- J Lawler
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - M Choynowski
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - K Bailey
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - M Bucholc
- EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Derry, /Londonderry, UK
| | - A Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - M Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland.,EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Derry, /Londonderry, UK
| |
Collapse
|
25
|
Donlon NE, Mohan H, Free R, Elbaghir B, Soric I, Fleming C, Balasubramanian I, Ivanovski I, Schmidt K, Mealy K. Predictive value of CRP/albumin ratio in major abdominal surgery. Ir J Med Sci 2020; 189:1465-1470. [DOI: 10.1007/s11845-020-02238-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/16/2020] [Indexed: 01/06/2023]
|
26
|
Qi AC, Peacock K, Luke AA, Barker A, Olsen MA, Joynt Maddox KE. Associations Between Social Risk Factors and Surgical Site Infections After Colectomy and Abdominal Hysterectomy. JAMA Netw Open 2019; 2:e1912339. [PMID: 31577353 PMCID: PMC6777422 DOI: 10.1001/jamanetworkopen.2019.12339] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Surgical site infection (SSI) is an important patient safety outcome. Although social risk factors have been linked to many adverse health outcomes, it is unknown whether such factors are associated with higher rates of SSI. OBJECTIVES To determine whether social risk factors, including race/ethnicity, insurance status, and neighborhood income, are associated with higher rates of SSI after colectomy or abdominal hysterectomy, 2 surgical procedures for which SSI rates are publicly reported and included in pay-for-performance programs by Medicare and other groups. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed adults undergoing colectomy or abdominal hysterectomy, as captured in State Inpatient Databases for Arizona, Florida, Iowa, Massachusetts, Maryland, New York, and Vermont. Operations were performed in 2013 through 2014 at general acute care hospitals in the United States. Data analysis was conducted from October 2018 through June 2019. EXPOSURES Colectomy or hysterectomy. MAIN OUTCOMES AND MEASURES Postoperative complex SSI rates. RESULTS A total of 149 741 patients met the inclusion criteria, including 90 210 patients undergoing colectomies (mean [SD] age, 63.4 [15.6] years; 49 029 [54%] female; 74% white, 11% black, 9% Hispanic, and 5% other or unknown race/ethnicity) and 59 531 patients undergoing abdominal hysterectomies (mean [SD] age, 49.8 [11.8] years; 100% female; 52% white, 26% black, 14% Hispanic, and 8% other or unknown race/ethnicity). In the colectomy cohort, 34% had private insurance, 52% had Medicare, 9% had Medicaid, and 5% had other or unknown insurance or were uninsured; 24% were from the lowest quartile of median zip code income. In the hysterectomy cohort, 57% had private insurance, 16% had Medicare, 19% had Medicaid, and 3% had other or unknown insurance or were uninsured; 27% were from the lowest-income zip codes. Within 30 days of surgery, SSI rates were 2.55% for the colectomy cohort and 0.61% for the hysterectomy cohort. For colectomy, black race (adjusted odds ratio [AOR], 0.71; 95% CI, 0.61-0.82) was associated with lower odds of SSI, whereas Medicare (AOR, 1.25; 95% CI, 1.10-1.41), Medicaid (AOR, 1.23; 95% CI, 1.06-1.44), and low neighborhood income (AOR, 1.14; 95% CI, 1.01-1.29) were associated with higher odds of SSI. For hysterectomy, no social risk factors that were examined in this study had statistically significant associations with SSI after adjustment for clinical risk. CONCLUSIONS AND RELEVANCE Inconsistent associations between social risk factors and SSIs were found. For colectomy, infection prevention programs targeting low-income groups may be important for reducing disparities in this postoperative outcome, and policy makers could consider taking social risk factors into account when evaluating hospital performance.
Collapse
Affiliation(s)
- Andrew C. Qi
- Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Kate Peacock
- Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alina A. Luke
- Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Abigail Barker
- Brown School of Social Work, Washington University in St Louis, St Louis, Missouri
| | - Margaret A. Olsen
- Washington University School of Medicine in St Louis, St Louis, Missouri
| | | |
Collapse
|
27
|
McGee MF, Kreutzer L, Quinn CM, Yang A, Shan Y, Halverson AL, Love R, Johnson JK, Prachand V, Bilimoria KY. Leveraging a Comprehensive Program to Implement a Colorectal Surgical Site Infection Reduction Bundle in a Statewide Quality Improvement Collaborative. Ann Surg 2019; 270:701-711. [PMID: 31503066 PMCID: PMC7775039 DOI: 10.1097/sla.0000000000003524] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Our objective was to examine the implementation and associated clinical outcomes of a comprehensive surgical site infection (SSI) reduction bundle in a large statewide surgical quality improvement collaborative leveraging a multifaceted implementation strategy. SUMMARY BACKGROUND DATA Bundled perioperative interventions reduce colorectal SSI rates when enacted at individual hospitals, but the ability to implement comprehensive SSI bundles and to examine the resultant clinical effectiveness within a larger, diverse population of hospitals is unknown. METHODS A multifaceted SSI reduction bundle was developed and implemented in a large statewide surgical quality improvement collaborative through a novel implementation program consisting of guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence and ACS NSQIP outcomes were examined preimplementation versus postimplementation. RESULTS Among 32 hospitals, there was a 2.5-fold relative increase in the proportion of patients completing at least 75% of bundle elements (preimplementation = 19.5% vs. postimplementation = 49.8%, P = 0.001). Largest adherence gains were seen in wound closure re-gowning/re-gloving (24.0% vs. 62.0%, P < 0.001), use of clean closing instruments (32.1% vs. 66.2%, P = 0.003), and preoperative chlorhexidine bathing (46.1% vs. 77.6%, P < 0.001). Multivariable analyses showed a trend toward lower risk of superficial incisional SSI in the postimplementation period compared to baseline (OR 0.70, 95% CI 0.49-10.2, P = 0.06). As the adherence in the number of bundle elements increased, there was a significant decrease in superficial SSI rates (lowest adherence quintile, 4.6% vs. highest, 1.5%, P < 0.001). CONCLUSIONS A comprehensive multifaceted SSI reduction bundle can be successfully implemented throughout a large quality improvement learning collaborative when coordinated quality improvement activities are leveraged, resulting in a 30% decline in SSI rates. Lower superficial SSI rates are associated with the number of adherent bundle elements a patient receives, rendering considerable benefits to institutions capable of implementing more components of the bundle.
Collapse
Affiliation(s)
- Michael F McGee
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lindsey Kreutzer
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Christopher M Quinn
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anthony Yang
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ying Shan
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amy L Halverson
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Remi Love
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Julie K Johnson
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Vivek Prachand
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Department of Surgery, University of Chicago, Chicago, IL
| | - Karl Y Bilimoria
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|