The Surgical Care Improvement Project Antibiotic Guidelines: Should We Expect More Than Good Intentions?

Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic guidelines and postoperative infections

OBJECTIVES

The study objectives were to measure the association among the 4 components of Society of Thoracic Surgeons antibiotic guidelines and postoperative complications in a cohort of patients undergoing valve or coronary artery bypass grafting requiring cardiopulmonary bypass.

METHODS

In this retrospective observational study, adult patients undergoing coronary revascularization or valvular surgery who received a Surgical Care Improvement Project-compliant antibiotic from January 1, 2016, to April 1, 2021, at a single, tertiary care hospital were included. The primary exposures were adherence to the 4 individual components of Society of Thoracic Surgeons antibiotic best practice guidelines. The association of each component and a combined metric was tested in its association with the primary outcome of postoperative infection as determined by Society of Thoracic Surgeons data abstractors, controlling for several known confounders.

RESULTS

Of the 2829 included patients, 1084 (38.3%) received care that was nonadherent to at least 1 aspect of Society of Thoracic Surgeons antibiotic guidelines. The incidence of nonadherence to the 4 individual components was 223 (7.9%) for timing of first dose, 639 (22.6%) for antibiotic choice, 164 (5.8%) for weight-based dose adjustment, and 192 (6.8%) for intraoperative redosing. In adjusted analyses, failure to adhere to first dose timing guidelines was directly associated with Society of Thoracic Surgeons-adjudicated postoperative infection (odds ratio, 1.9; 95% confidence interval, 1.1-3.3; P = .02). Failure of weight-adjusted dosing was associated with both postoperative sepsis (odds ratio, 6.9; 95% confidence interval, 2.5-8.5; P < .01) and 30-day mortality (odds ratio, 4.3; 95% confidence interval, 1.7-11.4; P < .01). No other significant associations among the 4 Society of Thoracic Surgeons metrics individually or as a combination were observed with postoperative infection, sepsis, or 30-day mortality.

CONCLUSIONS

Nonadherence to Society of Thoracic Surgeons antibiotic best practices is common. Failure of antibiotic timing and weight-adjusted dosing is associated with odds of postoperative infection, sepsis, and mortality after cardiac surgery.

Applying Decision Science to the Prioritization of Healthcare-Associated Infection Initiatives

OBJECTIVES

Improving patient quality remains a top priority from the perspectives of both patient outcomes and cost of care. The continuing threat to patient safety has resulted in an increasing number of options for patient safety initiatives, making choices more difficult because of competing priorities. This study provides a proof of concept for using low-cost decision science methods for prioritizing initiatives.

METHODS

Using multicriteria decision analysis, we developed a decision support model for aiding the prioritization of the four most common types of healthcare-associated infections: surgical site infections, central line-associated bloodstream infections, ventilator-associated events, and catheter-associated urinary tract infections. In semistructured interviews, we elicited structure and parameter values of a candidate model, which was then validated by six participants with different roles across three urban teaching and nonteaching hospitals in the Baltimore, Maryland area.

RESULTS

Participants articulated the following structural attributes of concern: patient harm, monetary costs, patient mortality, reputational effects, and patient satisfaction. A quantitative decision-making model with an associated uncertainty report for prioritizing initiatives related to the four most common types of healthcare-associated infections was then created.

CONCLUSIONS

A decision support methodology such as our proof of concept could aid hospital executives in prioritizing the quality improvement initiatives within their hospital, with more complete data. Because hospitals continue to struggle in improving quality of care with tighter budgets, a formal decision support mechanism could be used to objectively prioritize patient safety and quality initiatives.

Impact of Reduced Preincision Antibiotic Infusion Time on Surgical Site Infection Rates: A Retrospective Cohort Study

OBJECTIVE

Our objective was to determine the impact of total preincision infusion time on surgical site infections (SSIs) and establish an optimal time threshold for subsequent prospective study.

BACKGROUND

SSIs remain a major cause of morbidity. Although regulated, the total time of infusion of preincision antibiotics varies widely. Impact of infusion time on SSI risk is poorly understood.

METHODS

All consecutive patients (n = 46,791) undergoing inpatient surgical intervention were retrospectively enrolled (2014-2015) and monitored for 1 year. Primary outcomes: the presence of SSI infection as predicted by reduced preoperative antibiotic infusion time.

SECONDARY OUTCOMES

preintervention compliance, the impact of a quality improvement algorithm to optimize infusion time compliance. Multivariate logistic regression of the retrospective cohort demonstrated predictors of infection. Receiver-operating characteristic analysis demonstrated the timing threshold predictive of infection. Cost impact of avoidable infections was analyzed.

RESULTS

Only 36.1% of patients received preincision infusion of vancomycin in compliance with national and institutional standards (60-120 min). Cephalosporin infusion times were 53 times more likely to be compliant [odds ratio (OR) 53.33, P < 0.001]. Vancomycin infusion times that were not compliant with national standards (less than standard 60-120 min) did not predict infection. However, significantly noncompliant, reduced preincision infusion time, significantly predicted SSI (<24.6 min infusion, AUC = 0.762). Vancomycin infusion, initiated too close to surgical incision, predicted increased SSI (OR = 4.281, P < 0.001). Implementation of an algorithm to improve infusion time, but not powered to demonstrate infection /reduction, improved vancomycin infusion start time (257% improvement, P < 0.001) and eliminated high-risk infusions (sub-24.6 min).

CONCLUSIONS

Initially, vancomycin infusion rarely met national guidelines; however, minimal compliance breach was not associated with SSI implications. The retrospective data here suggest a critical infusion time for infection reduction (24.6 min before incision). Prospective implementation of an algorithm led to 100% compliance. These data suggest that vancomycin administration timing should be studied prospectively.

Patient satisfaction survey scores are not an appropriate metric to differentiate performance among anesthesiologists

STUDY OBJECTIVE

With the focus of patient-centered care in healthcare organizations, patient satisfaction plays an increasingly important role in healthcare quality measurement. We sought to determine whether an automated patient satisfaction survey could be effectively used to identify outlying anesthesiologists.

DESIGN

Retrospective Observational Study.

SETTING

Vanderbilt University Medical Center (VUMC).

MEASUREMENTS

Patient satisfaction data were obtained between October 24, 2016 and November 1, 2017. A multivariable ordered probit regression was conducted to evaluate the relationship between the mean scores of responses to Likert-scale questions on SurveyVitals' Anesthesia Patient Satisfaction Questionnaire 2. Fixed effects included demographics, clinical variables, providers and surgeons. Hypothesis tests to compare each individual anesthesiologist with the median-performing anesthesiologist were conducted.

MAIN RESULTS

We analyzed 10,528 surveys, with a 49.5% overall response rate. Younger patient (odds ratio (OR) 1.011 [per year of age]; 95% confidence interval (CI) 1.008 to 1.014; p < 0.001), regional anesthesia (versus general anesthesia) (OR 1.695; 95% CI 1.186 to 2.422; p = 0.004) and daytime surgery (versus nighttime surgery) (OR 1.795; 95% CI 1.091 to 2.959; p = 0.035) were associated with higher satisfaction scores. Compared with the median-ranked anesthesiologist, we found the adjusted odds ratio for an increase in satisfaction score ranged from 0.346 (95% CI 0.158 to 0.762) to 1.649 (95% CI 0.687 to 3.956) for the lowest and highest scoring providers, respectively. Only 10.10% of anesthesiologists at our institution had an odds ratio for satisfaction with a 95% CI not inclusive of 1.

CONCLUSIONS

Patient satisfaction is impacted by multiple factors. There was very little information in patient satisfaction scores to discriminate the providers, after adjusting for confounding. While patient satisfaction scores may facilitate identification of extreme outliers among anesthesiologists, there is no evidence that this metric is useful for the routine evaluation of individual provider performance.

Subscapularis-Sparing Rotator Interval Approach for Anatomic Total Shoulder Arthroplasty

Background

A subscapularis-sparing approach to anatomic total shoulder arthroplasty (TSA) is used for patients with glenohumeral osteoarthritis who have an intact rotator cuff and sufficient bone volume.

Description

A 7 to 10-cm anterosuperior incision is made with the patient in the beach chair position. The anterolateral deltoid muscle raphe is split, and the shoulder is externally rotated to bring the rotator interval to the field. A flap of interval tissue is incised, tenodesis of the biceps tendon is performed, and the interval tissue is incised straight back to the glenoid from the upper edge of the subscapularis, creating a triangular piece of tissue referred to as a "trapdoor." Two Darrach retractors are placed to expose the humeral head. An intramedullary guide is placed, and a humeral head osteotomy is performed. The glenoid is exposed, and the glenoid component is placed after sizing, preparation, drilling, and insertion of trial components per the surgical technique. The humeral head size is estimated by measuring, and the humeral stem size is decided by sequentially inserting the trial components. The permanent humeral stem is inserted, and the permanent humeral head is implanted after insertion of trial components. The trapdoor is sutured, the deltoid is reattached, and subcutaneous tissue and skin are sutured.

Alternatives

The traditional surgical approach for anatomic TSA involves release and reattachment of the subscapularis tendon.

Rationale

Nearly all anatomic TSA techniques require the subscapularis to be released, with a peel, tenotomy, or osteotomy, and then repaired on completion of the arthroplasty. Failure of the subscapularis to heal is an unfortunate and potentially devastating complication following anatomic TSA that has been linked to decreased function, instability, and pain^1-4. Subscapularis dysfunction following anatomic TSA is seen in one-third to two-thirds of patients, with evidence of complete tears in up to 50% of asymptomatic patients using ultrasound examinations^1-5.Sling immobilization with avoidance of excessive passive external rotation and active internal rotation is recommended to help prevent postoperative rupture of the subscapularis repair^6-8. However, postoperative motion restrictions to protect the subscapularis may lead to stiffness and may negatively impact function and satisfaction.We describe a subscapularis-sparing TSA, in which we address and improve on 3 technical difficulties identified by Lafosse et al.⁹: (1) difficulty ensuring an anatomic humeral neck cut because of the difficulty visualizing the anterior aspect of the shoulder, (2) inadequate resection of inferior humeral neck osteophytes, and (3) undersizing of the humeral head.

Is There a Difference in Infection Risk Between Single and Multiple Doses of Prophylactic Antibiotics? A Meta-analysis

BACKGROUND

The prevention of surgical site infection guidelines issued by the Centers for Disease Control and Prevention (CDC) recently recommended that only a single dose of preoperative antibiotics be administered to patients undergoing clean-contaminated procedures based on data from a variety of surgical disciplines. For orthopaedic procedures, where postoperative infections can have significant consequences, the existing evidence for this recommendation is widely debated.

QUESTIONS/PURPOSES

Is there a difference in postoperative infection risk when utilizing a single dose of preoperative antibiotics compared with multiple doses of perioperative antibiotics for orthopaedic procedures where implants are placed?

METHODS

MEDLINE, EMBASE, Google Scholar, and Cochrane were systematically reviewed for randomized controlled trials (RCTs) of a single dose of preoperative antibiotics compared with pre- and postoperative prophylaxis from 1980 to 2017 for all orthopaedic procedures where implants were being placed. Infection (both superficial and deep) as a primary outcome through all available followup was required for inclusion. Fourteen RCTs detailing 9691 orthopaedic procedures were included for analysis, including seven arthroplasty, one spine, and six general orthopaedic trials (two specific to hip fracture fixation). Pooled infection outcomes were analyzed with random-effects modeling in light of study heterogeneity. Bias was evaluated using the Cochrane risk of bias tool as well as a funnel plot for publication bias, and quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Bias was largely uncertain; however, a high risk of bias was noted in four studies. No significant overall publication bias was noted. The quality of evidence was determined to be very low based on the GRADE tool, downgraded based on risk of bias, inconsistency, and imprecision. Despite the quality of evidence, the data were pooled in light of the current recommendations from the CDC to critically evaluate the recommendation that a single dose of antibiotics be utilized.

RESULTS

There were no differences in infection risk between single- versus multiple-dose groups (single: 83 of 4263 [2%], multiple: 101 of 5428 [2%]; odds ratio, 0.92 [95% confidence interval, 0.56-1.51]; p = 0.740, I = 36% for statistical heterogeneity).

CONCLUSIONS

There is no difference in infection risk between a single dose and multiple doses of perioperative antibiotics for orthopaedic procedures where implants are utilized, consistent with recent recommendations. However, the quality of evidence for orthopaedic procedures is low, and a randomized study with a sufficient sample size is needed to examine the issue before universal adoption of a single antibiotic dose.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Comparison of Surgical Site Infections in Ankle Fracture Surgery With or Without the Use of Postoperative Antibiotics

BACKGROUND

Surgeon preference has been replaced by an approach using evidence-based medicine in clinical decision making. The use of postoperative antibiosis in ankle fracture surgery is more common for inpatients but variable for outpatient surgery. Some surgeons prefer to prescribe 24 hours of oral antibiotics, whereas others give no antibiotics at all postoperatively. In this study, inpatients receiving 24 hours of intravenous antibiotics were compared to those patients receiving 24 hours of oral antibiotics and those receiving no postoperative antibiotics.

METHODS

A total of 1442 patients with ankle fractures requiring operative fixation were retrospectively reviewed in this multicenter study. Demographic data including age, sex, and body mass index were collected. Clinical data including diabetes status, smoking status, hepatitis C virus (HCV) or human immunodeficiency virus (HIV) status, infection requiring additional antibiotics, and infection requiring return to operating room (RTOR) were compared across the groups.

RESULTS

No differences in incidence of cellulitis or return to OR for infection were demonstrated between the 3 groups. No differences were noted among the groups for any risk factors for infection including body mass index, previous infection, smoking status, HCV/HIV status, or diabetes. The rates of cellulitis ( P = .402), infection requiring additional antibiotics ( P = .563), and infection requiring return to the operating room ( P = .878) showed no difference between the groups.

CONCLUSION

The use of antibiotics postoperatively did not decrease the incidence of surgical site infection. The findings in this study suggest that the routine use of postoperative antibiotics after ankle fracture surgery is not beneficial.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Perioperative antibiotics should be used for placement of implanted central venous ports: A propensity analysis evaluating risk

OBJECTIVE

To quantify risk for CRI based on PABX use in CVAP placement for cancer patients.

SUMMARY BACKGROUND DATA

Central venous access ports (CVAP) are totally implanted devices used for chemotherapy. There is a temporal risk for catheter related infection (CRI) to insertion and perioperative prophylactic antibiotics (PABX) use is a contested issue among practitioners.

METHODS

Data was collected from a single center, academic oncology center. Treatment with a perioperative PABX was compared to non-treatment, to examine the incidence of 14-day CRI. Propensity scores with matched weights controlled for confounding, using 15 demographic, procedural and clinical variables.

RESULTS

From 2007 to 2012, 1,091 CVAP were placed, where 59.7 % received PABX. The 14-day CRI rate was 0.82%, with 78% of those not receiving PABX. While results did not achieve statistical significance, use of PABX was associated with a 58% reduction in the odds of a 14-day CRI (OR = 0.42, 95% CI: 0.08-2.24, p = 0.31).

CONCLUSION

The findings suggest a reduction in early CRI with the use of PABX. Since CRI treatment can range from a course of oral antibiotics, port removal, to hospital admission, we suggest clinicians consider these data when considering PABX in this high-risk population.

Recent Anti-Microbial Exposure Is Associated with More Complications after Elective Surgery

BACKGROUND

Recent anti-microbial exposure has been associated with poor outcomes after infection in a mixed population. We hypothesized that recent anti-microbial exposure would be associated with poor outcomes of elective surgery.

METHODS

From August 2015 to August 2016, all elective surgical patients were questioned prospectively about anti-microbial exposure during the prior three months. Multivariable models were used to calculate risk-adjusted odds ratios for anti-microbial exposure controlling for surgeon influence. Primary outcomes were any serious complication, any complication, any infection, and surgical site infection. Secondary outcomes were length of stay, C. difficile infection, and death. A separate analysis of patients excluding those having colorectal surgery who had undergone an oral antibiotic bowel preparation also was performed.

RESULTS

Ninety-four percent of eligible patients (n = 1,538) answered the exposure question, with a three-month anti-microbial exposure rate of 34.1%. Colorectal surgery patients had the highest exposure rate, whereas hernia patients had the lowest. Exposed patients had higher rates of any complication, any infection, and surgical site infection, as well as a median two-day longer hospital stay. There were no differences in C. difficile infection or death between the groups. After risk adjustment, anti-microbial exposure was independently associated with any serious complication for all patients as well as with complications and infection in patients having an operation other than colorectal surgery.

CONCLUSION

Recent anti-microbial exposure is associated with more complications of elective surgery. Anti-microbial drug-induced alterations in microbiome-related inflammatory responses may play a role, highlighting an opportunity for pre-surgical intervention in this at-risk population.

Perioperative Information Systems: Opportunities to Improve Delivery of Care and Clinical Outcomes in Cardiac and Vascular Surgery

A variety of existing perioperative informatics tools offer clinicians and researchers the opportunity to improve the delivery of care and clinical outcomes for patients undergoing cardiac and vascular surgery. Many of these tools can be used to improve the reliability of the care delivery process through the application of clinical decision support tools and/or quality improvement methodologies at a number of junctures. In this review, the authors will offer a concise overview of the existing perioperative informatics literature, with a focus on tools considered to be of utility in confronting the unique challenges inherent to cardiac and vascular surgery. The authors also highlight areas that they believe are of interest for future targeted inquiry.

An Audit of Perioperative Antimicrobial Prophylaxis: Compliance with the International Guidelines

Objective:

Antimicrobial prophylaxis has been demonstrated to lower the incidence of postoperative infection in nearly all types of surgery. The American Society of Health-System Pharmacists (ASHP) guideline summarizes current data on the appropriate use of antibiotic for surgical prophylaxis. The objective of this study was to assess and audit the use of antibiotics in a tertiary care center according to the recommendation of ASHP guideline.

Methods:

This cross-sectional study was performed using prospective data gathered from April to September 2015 in the surgical wards of Al Zahra Hospital, Isfahan, Iran. Antibiotic indication and choice, dose, dosing interval, route of administration, and timing of first administration and duration of prophylaxis were compared with the ASHP guideline recommendations.

Findings:

A total of 100 patients with the mean age of 49.8 ± 18.2 years were recruited for this study. About 22% of procedures had full compliance with all guideline recommendations. The most frequently encounter noncompliance type were the duration of prophylaxis (14%) and appropriate agent choice (35%). Timing of the initial dose was appropriate in most of the procedures (42%).

Conclusion:

This study revealed that most of the prescribed antibiotics for surgical prophylaxis are not in accordance with standard treatment guideline. The density of antimicrobial use for preoperative antimicrobial prophylaxis is very high. Furthermore, the hospital should develop a formal strategy, including a local guideline for antimicrobial prophylaxis in surgical procedures.

Quality and Safety in Health Care, Part XVI: The VA Surgical Quality Improvement Program

As the result of a congressional mandate, the Veterans Health Administration (VA) undertook an initiative called the National VA Surgical Risk study. The purpose of this study was to collect information on its surgical patients to determine outcome data, adjusted for patient risk factors. In 1994, the VA started its National Surgical Quality Improvement Program (VASQIP). These efforts were one of the earliest well-done nationwide systems to study and improve outcomes in surgery adjusted for patient risk. Between 1991 and 2006, the VA hospitals observed a decrease of mortality of 47% and a decrease of morbidity of 43% of their patients in the first 30 days after an operation.