Improving Statewide Post-Operative Sepsis Performance Measurement Using Hospital Risk Adjustment Within a Surgical Collaborative

Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.

Risk factors for the systemic inflammatory response syndrome and sepsis following surgical management of acute intestinal obstruction

OBJECTIVES

Infection is one of the major complications following intestinal obstruction surgery, yet predictors of its occurrence are not sufficiently reported. In this study, we examine the factors leading to postoperative inflammatory response syndrome (SIRS) and sepsis.

METHODS

The data of 213 patients who underwent intestinal obstruction surgery between 2015 to 2020 in King Abdulaziz Medical City, Riyadh, Saudi Arabia, were reviewed retrospectively. Patients' demographic characteristics and preoperative, intraoperative, and 30-day postoperative data were compared between patients who had postoperative SIRS/sepsis and patients who had no complications.

RESULTS

Ninety-six patients (44%) developed SIRS/sepsis within 30 days after surgery. More than half of the patients were males (55.8%), and the mean age at operation was 56.7(SD=20.0)years. Preoperative high heart rate, low albumin levels, and postoperative intensive care unit (ICU) admission were independently and significantly associated with developing SIRS/sepsis post-operation. The mortality rate in this study was estimated to be 7.5%; of those, 93.8% had SIRS/sepsis.

CONCLUSION

The 30-day mortality rate is considerably higher among patients who developed SIRS/sepsis after intestinal obstruction surgery. The independent risk factors of developing SIRS/sepsis after operation were elevated heart rate, low albumin levels preoperation, and ICU admission post-operation.

Risk Factors for Post-Operative Sepsis and Septic Shock in Patients Undergoing Emergency Surgery

Background: Sepsis after emergency surgery is associated with a higher mortality rate than elective surgery, and total hospital costs increase by 2.3 times. This study aimed to identify risk factors for post-operative sepsis or septic shock in patients undergoing emergency surgery. Methods: A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program (NSQIP) by identifying patients undergoing emergency surgery between 2012 and 2015 and comparing those who developed post-operative sepsis or septic shock (S/SS) with those who did not. Patients with pre-operative sepsis or septic shock were excluded. Multiple logistic regression was used to identify risk factors for the development of S/SS in patients undergoing non-elective surgery. Results: Of 122,281 patients who met the inclusion criteria, 2,399 (2%) developed S/SS. Risk factors for S/SS were American Society of Anesthesiologists Physical Status (ASA PS) class 2 or higher (odds ratio [OR] 2.57; 95% confidence interval [CI] 2.19-3.02; p < 0.0001), totally dependent (OR 2.00, 95% CI 1.38-2.83; p = 0.00021) or partially dependent (OR 1.62, 95% CI 1.35-2.00; p < 0.0001) functional status, and male gender (OR 1.31; 95% CI 1.18-1.45; p < 0.0001). Compared with colorectal procedures, patients undergoing pancreatic (OR 2.33, CI 1.40-3.87; p = 0.00108) and small intestine (OR 1.27; CI 1.12-1.44; p = 0.00015) surgery were more likely to develop S/SS. Patients undergoing biliary surgery (OR 0.38; CI 0.30-0.48; p < 0.0001) were less likely to develop S/SS. Conclusions: Risk factors for the development of sepsis or septic shock are ASA PS class 2 or higher, partially or totally dependent functional status, and male gender. Emergency pancreatic or small intestinal procedures may confer a higher risk. Greater vigilance and early post-operative screening may be of benefit in patients with these risk factors.

Bacterial Aetiology and Antibiotic Susceptibility Profile of Post-Operative Sepsis among Surgical Patients in a Tertiary Hospital in Rural Eastern Uganda

Background:

Post-operative wound sepsis remains a surgical challenge of public health concern constituting approximately 20% of the health care-associated nosocomial infections. This study aimed at determining the prevalence and antimicrobial resistance patterns of bacterial pathogens isolated from post-operative wound infections at Mbale Regional Referral Hospital.

Materials and Methods:

This was a descriptive cross-sectional study conducted from June to October 2015. Study participant samples were sub-cultured upon reception in the Microbiology laboratory and the isolated bacterial pathogens were analysed. Phenotypic antimicrobial susceptibility profiles were determined using the Kirby-Bauer method. Interpretation of the zone diameters was done following the Clinical and Laboratory Standards Institute guidelines. Phenotypic screening for Methicillin-resistant Staphylococcus aureus (MRSA) was performed using oxacillin (1 μg). D-test was also performed for phenotypic screening of inducible clindamycin resistant Staphylococcus aureus, Data were entered into Microsoft Excel and analysed using IBM SPSS statistics (version 16).

Results:

Overall post-operative sepsis was 69/80 (86.2%) with Staphylococcus aureus as the most predominant organism 41/104 (39.4%) followed by Escherichia coli 22/104 (21.2%) and Klebsiella species 15/104 (14.4%). Of the 41/104 isolated Staphylococcus aureus, 27/41(65.9%) were MRSA strains and 5/41 (12.2%) were inducible clindamycin resistant Staphylococcus aureus strains. The isolated Staphylococcus aureus was resistant to multiple drugs though susceptible to vancomycin and clindamycin. In addition, none of the isolated Enterococci species was vancomycin resistant. Although most of the isolated Gram-negative organisms were sensitive to imipenem, resistance was observed for tetracycline, trimethoprim/sulphamethoxazole, and ceftriaxone.

Conclusion:

Staphylococcus aureus was the most common causative agent associated with postoperative sepsis with most of the strains being MRSA. Multi-drug resistance was observed in 63/104 (60.6%) of the isolated organisms in our study. Hence the need to better develop and strengthen antimicrobial stewardship programs as well as to understand the carriage of antimicrobial resistance genes among these organisms.