Decrease In Surgical Site Infections Research Articles

Intrasite Antibiotic Powder for the Prevention of Surgical Site Infection in Extremity Surgery: A Systematic Review.

Although the role of intrasite antibiotic powder in preventing surgical site infections (SSIs) has been extensively explored in spinal surgery, it remains underevaluated in the other orthopaedic subspecialties. This systematic review examines the utilization of intrawound antibiotic powder as a prophylactic measure against SSIs in orthopaedic procedures. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, electronic searches were conducted on Ovid MEDLINE, and PubMed. Only English language, nonspine clinical studies published before May 2018 were included. The initial search identified 179 individual citations, and 11 studies met the eligibility criteria. All included studies were level III retrospective studies. Represented subspecialties included total joint arthroplasty, upper extremity, foot and ankle, and trauma. Eight studies demonstrated a statistically significant decrease in SSIs with the use of intrasite antibiotic powder. There are no current guidelines for the use of intrasite antibiotic powder for the prevention of SSIs in orthopaedic procedures. Despite the lack of high-quality evidence available in the literature, published smaller studies do suggest a significant protective effect. However, recommendations with regard to this technique after common orthopaedic procedures cannot yet be made.

Negative Pressure Wound Therapy (PICO) as a Means to Decrease Surgical Site Infection

Negative Pressure Wound Therapy (PICO) as a Means to Decrease Surgical Site Infection

Perioperative Harm Index facilitates prioritization of improvement initiatives

IntroductionPerioperative services constitute a significant portion of the care delivery, the impact, and the potential risk in healthcare organizations. Tremendous attention has been paid towards hospital-acquired conditions; however perioperative services have not received similar attention. There is a need for a standardized manner to report on conditions in perioperative services which facilitates prioritization of quality improvement initiatives. Materials and methodsPreventable harm and quality of care indicators were selected based on a review of the literature and available datasets, as well as from safety and quality measures in our organization. Metrics were derived from myriad national quality improvement initiatives and collaboratives. A structure was created to obtain the metrics in a near real-time manner and present the Perioperative Harm Index across the organization. Specific initiatives were targeted as necessitating immediate, short-term, or longer duration prioritization for improvement initiatives. ResultsA Perioperative Harm Index was created using 11 metrics that represent the spectrum of surgical care. The metrics facilitate prioritization of improvement initiatives and have resulted in improvement projects including perioperative normothermia in neonatal intensive care unit patients having procedures in the operating room, reduction of post-operative nausea and vomiting, and decrease in surgical site infections in selected procedures. ConclusionsA Perioperative Harm Index facilitates immediate shared understanding of the harm resulting from the care of surgical patients. As such, this index enables rapid and rationale prioritization for improvement activities. Our harm index is shared, is broadly generalizable, and has facilitated prioritization of improvement opportunities and appropriate allocation of improvement resources at our organization. Levels of EvidenceLevel V.

Setting intraoperative fraction of inspired oxygen

Each year, millions of patients undergo surgery under general anaesthesia. Oxygen, the most ubiquitous drug used in the operative setting, is often titrated to the anaesthesiologist preference. The choice of a high inspired fraction of inspired oxygen (FiO2) is commonplace. Safety criteria along with a debatable effect on a decrease in surgical site infection (SSI) are the potential reasons to justify a high FiO2 usage. Based on the latter, several organizations such as the World Health Organization (WHO) or Centers for Disease Control (CDC) have issued recommendations to keep high FiO2 during surgery and the immediate postoperative period. In this article, we will review the evidence behind these beneficial effects and several potential side effects of a high FiO2 intraoperative strategy.

Is it the technique or wound protection that is key to reducing wound infections in Roux-en-Y gastric bypass procedures?

An unusually high surgical site infection (SSI) rate after Roux-en-Y gastric bypass (RYGB) was noted on routine outcomes review. Surgeon A, who had a rate of 8.9%, utilized the transoral technique (passage down esophagus into gastric pouch) for anvil insertion for the circular-stapled gastrojejunostomy. By comparison, SSI rate was 0% for Surgeon B, who inserted anvil transabdominally (direct passage into stomach via gastrotomy) and used wound protection (wound protector and plastic drape over stapler). We sought to determine if it was the technique for anvil insertion (transoral or transabdominal) or use of wound protection that could help reduce SSIs. In mid-2017, Surgeon A added wound protection (wound protector and plastic drape over stapler) to the transoral technique to minimize oral flora wound contamination. Surgeon B made no changes. In this study, wound-related outcomes are examined, comparing patients who underwent surgery before (Group 1) versus after (Group 2) this intervention. Statistical analysis performed utilizing t tests and Chi square analysis; p < 0.05 considered significant. Three hundred and thirty-three patients underwent RYGB. Group 1 consisted of 182 patients over 17months; 151 patients over 13months were in Group 2. Groups were similar in age, BMI, gender, and prevalence of diabetes. There was a decrease in SSIs between Group 1 and Group 2 (5 vs. 0, p = 0.04). 11 wound complications occurred in Group 1 (5 SSIs, 4 seromas and 2 hematomas); whereas 2 wound complications occurred in Group 2 (1 seroma and 1 hematoma); decrease from 6 to 1.3%, p = 0.03. This study demonstrates that changing technique can lead to best outcomes. There was a dramatic reduction of wound complications and complete elimination of SSIs with a change in operative technique. The higher risk of SSI with the transoral anvil insertion when preforming a circular-stapled anastomosis can be mitigated with use of wound protection.

Effect of using silver nylon dressings to prevent superficial surgical site infection after cesarean delivery: a randomized clinical trial

Surgical site infections are associated with significant healthcare cost and burden. Silver-impregnated dressings have been associated with a decrease in surgical site infections in select populations, but it is unknown whether the benefit can be observed after cesarean deliveries. We sought to evaluate the impact of silver nylon dressings in reducing superficial surgical site infections after cesarean delivery. A blinded randomized clinical trial of women undergoing scheduled or unscheduled cesarean delivery at a single site was conducted. Women were recruited for participation from September 2013 to June 2016. Women with vertical skin incisions were excluded. Enrolled participants were randomized to silver nylon dressing or an identical-appearing gauze wound dressing. Wounds were evaluated in the outpatient office at 1 week and 6 weeks after delivery. The primary outcome was superficial surgical site infection as defined by Centers for Disease Control criteria at any time within the first 6 weeks after cesarean delivery. A sample size of 330 per group (n= 660) was planned to compare the 2 arms. Data were analyzed using the χ2, Fisher exact test, Student t test, Mann-Whitney U test, and logistic regression where appropriate, and a value of P < .05 was considered significant. Among the 657 participants, overall, the primary outcome was similar between the 2 groups (4.6% in the silver nylon group vs 4.2% in the gauze group, P= .96). Women allocated to silver nylon, when compared to those who were allocated to gauze, had similar rates of superficial surgical site infection within 1 week (1.2% vs 0.9%) and within 6 weeks ( 4.6% vs 4.2%) after delivery (P>.99). The 2 groups were similar in age (30.9 ± 5.6 vs 31.0 ± 5.5 years, P= .95), body mass index (36.2 ± 8.7 vs 35.3 ± 8.2 kg/m2, P= .19), pregestational diabetes (6.2% vs 3.4%, P= .14), gestational diabetes (7.9% vs 7.3%, P= .88), cesarean delivery after labor (31.9% vs 31.1%, P= .86), presence of chorioamnionitis (5.2% vs 2.1% P= .06), and operative time (56.4 ± 20.6 vs 55.9 ± 17 minutes, P= .69). After adjusting for clinical and sociodemographic confounding variables, current smoking (adjusted odds ratio, 4.9; 95% confidence interval, 1.8-13.4) body mass index ≥40 kg/m2 (adjusted odds ratio, 3.08; 95% confidence interval, 1.3-6.8), and surgery length (minutes) (adjusted odds ratio, 1.02; 95% confidence interval, 1.002-1.04), but not use of gauze dressing, were associated with superficial surgical site infections. Among women undergoing cesarean delivery, silver nylon dressing was not more effective than gauze in reducing the risk of superficial surgical site infections.

One size doesn't fit all: different antibiotics are associated with decreases in surgical site infections in pancreaticoduodenectomy versus distal pancreatectomy

Background: The utility of prophylactic antibiotics before skin incision to decrease surgical site infection is well-documented. However, there is limited data comparing the use of different classes of antibiotics to mitigate this risk in pancreatic surgery. Multiple different antibiotic regimens are utilized nationwide, and there remains a gap in knowledge as to the risks and benefits of various antibiotic choices. It is hypothesized that certain antibiotics may be associated with lower rates of surgical site infection in pancreatic procedures. Methods: Demographic, comorbidity, perioperative, intraoperative, and outcomes data were captured from the 2016 ACS National Surgical Quality Improvement Program (NSQIP) targeted pancreatectomy database. Pre-operative antibiotics were classified into first generation cephalosporin (1stCE), second or third generation cephalosporin (2-3CE), and broad-spectrum antibiotics (br-ABX). Br-ABX include anti-pseudomonals, ticarcillin-clavulanate, piperacilin/tazobactam, fourth generation cephalosporins, aminoglycosides, and fluoroquinolones. Univariate and multivariate analysis was performed to compare various outcomes between the different groups. Subset analysis was performed by surgery type (pancreaticoduodenectomy vs. distal pancreatectomy) and approach (open vs. minimally invasive (MIS)). Distal pancreatectomy with enteric reconstruction were excluded. The primary end-point was surgical site infection. Results: Of the 5,803 pancreatectomies performed throughout the U.S. in 2016, 38% received a first generation cephalosporin (1CE), 26% a second or third generation cephalosporin (2-3CE), and 36% a broad spectrum antibiotic (br-ABX). After controlling for patient demographics, comorbidities, perioperative variables including blood administration, gland characteristics, receipt of neoadjuvant therapy, stent and drain use; br-ABX, and not 2-3CE, was associated with a decrease in superficial surgical site infection (SSI) (OR = 0.67, p = 0.014) and organ space SSI (OR = 0.81, p = 0.05) compared to 1CE. The decreases in SSI occurred after open and not MIS pancreatectomy (p < 0.006). Subset analysis identified that the br-ABX-associated decrease in superficial and organ space SSIs were only associated with open pancreaticoduodenectomy (superficial: p = 0.003; organ space: p = 0.025), and not open distal pancreatectomy. Interestingly, an increase in organ space SSI was observed with br-ABX for MIS distal pancreatectomy (OR = 3.15, p = 0.002). For all pancreatectomies, there was a two-fold increase in clostridium difficile infection with 2-3CE (OR = 2.08, p=0.014), and a two-fold decrease in urinary tract infections (UTI) with Br-abx (OR = 0.52, p = 0.012), compared to 1CE. There were no differences in deep incisional SSI, wound dehiscence, sepsis, and length of stay or readmission rates across all groups of antibiotics. Conclusion: Broad-spectrum antibiotics are associated with decreased SSIs after open pancreaticoduodenectomy, but increased SSIs after MIS distal pancreatectomy. There was no difference in SSI for MIS pancreaticoduodenectomy or open distal pancreatectomy regardless of antibiotic regimen. Thus, since 2-3CE were associated increased clostridium difficile infection, Br-ABX may be appropriate for open pancreaticoduodenectomy, and 1CE for MIS pancreatectomy and all distal pancreatectomy in order to decrease SSIs. Prospective trials are warranted.

Antibiotic prophylaxis: current recommendations in plastic surgery

Guidelines for prophylactic antibiotics in surgery have long been established; however, few have focused on recommendations in plastic surgery. Surgical site infection rates remain low, yet the use of prophylactic antibiotics has surged in the past 30 years. This article summarizes current recommendations of prophylactic antibiotic use to produce consensus guidelines in plastic surgery. A literature review was conducted in the PubMed, Cochrane, and Ovid databases and studies were included if randomized controlled trials indicated a statistically significant decrease in surgical site infections. Surveys conducted by the American Society of Plastic Surgeons regarding prophylactic antibiotic use from 1975, 1985, 2000, and 2010 were compiled and analyzed. Of 143 articles found, nine randomized controlled trials showed a reduction in surgical site infections after antibiotic prophylaxis for specific plastic surgery procedures. There are evidence-based recommendations for prophylactic antibiotics in breast surgery, abdominoplasty, contaminated hand or face surgery, prosthetic surgery, rhinoplasty, microsurgery, and acute and burn reconstruction cases. The proportion of plastic surgeons using prophylactic antibiotics has steadily increased from 1975 to 2010 with a significant increase from 2000 to 2010. Systemic antibiotic prophylaxis is recommended for use in breast surgery, abdominoplasty, contaminated hand or face surgery, prosthetic surgery, rhinoplasty, microsurgery, and acute and burn reconstruction cases. Recent surveys indicate that the majority of plastic surgeons continue to use prophylactic antibiotics in clean cases of the hand, face, and body despite recommendations. Additional procedure-specific randomized controlled trials are necessary to provide evidence-based recommendations for antibiotic prophylaxis in plastic surgery. Level of Evidence: Level IV, risk / prognostic study

Surgical Site Infections in Spine Surgery: Preoperative Prevention Strategies to Minimize Risk.

Study Design:Literature review.Objectives:A review of the literature identifying preoperative risk factors for developing surgical site infections after spine surgery and discussion of the preventive strategies to minimize risks.Methods:A review of the literature and synthesis of the data to provide an updated review on the preoperative management of surgical site infection.Results:Preoperative prevention strategies of reducing surgical site infections in spine surgery remains a challenging problem. Careful mitigation of modifiable patient comorbidities, blood glucose control, smoking, obesity, and screening for pathologic microorganisms is paramount to reduce this risk. Individualized antibiotic regimens, skin preparation, and hand hygiene also play a critical role in surgical site infection prevention.Conclusions:This review of the literature discusses the preoperative preventive strategies and risk management techniques of surgical site infections in spine surgery. Significant decreases in surgical site infections after spine surgery have been noted over the past decade due to increased awareness and implementation of the prevention strategies described in this article. However, it is important to recognize that prevention of surgical site infection requires a system-wide approach that includes the hospital system, the surgeon, and the patient. Continued efforts should focus on system-wide implementation programs including careful patient selection, individualized antibiotic treatment algorithms, identification of pathologic organisms, and preoperative decolonization programs to further prevent surgical site infections and optimize patient outcomes.

111. Increasing Duration of Surgical Prophylaxis Increases Antimicrobial-Associated Adverse Events but Does Not Decrease Surgical Site Infections: An Opportunity for Stewardship

BackgroundThe benefits of surgical antimicrobial prophylaxis are limited to the first 24 hours postoperatively. However, little is known about the harms associated with prophylaxis lasting for greater than 24 hours. Thus, we sought to characterize the relationship between duration of prophylaxis and key post-operative outcomes, including surgical site infections (SSI), acute kidney injuries (AKI), and C. difficile infections (CDI) using a large, multi-center national cohort.MethodsAll patients who underwent cardiac, orthopedic total joint, vascular, and colorectal procedures and who received planned manual review by a trained nurse reviewer for type and duration of surgical prophylaxis and for SSI within the national VA healthcare system during the period from FY08 to FY13 were included. The primary exposure variable of interest was duration of postoperative prophylaxis (<24 hours, 24–48 hours, and 48+ hours). Outcomes evaluated included SSI, AKI, and CDI. ORs were calculated using log binomial regression models adjusted for known risk factors for each clinical syndrome selected a priori.ResultsOut of a total cohort of 79,092, all patients had SSI and C. difficile outcomes available and 67,729 patients had AKI outcome available. After stratification by type of surgery and adjusting for age, sex, race, diabetes, smoking, pre-operative MRSA colonization status, mupirocin receipt, and type of prophylaxis, there was no significant association between SSI and duration of prophylaxis; longer durations did not lead to additional SSI reduction. Odds of AKI increased with each additional day of prophylaxis among cardiac and noncardiac surgeries. Similarly, the odds of C. difficile increased with each additional day of prophylaxis across all types of surgery (P < 0.01) (see figure).ConclusionIncreasing duration of postoperative antimicrobial prophylaxis is associated with higher odds of AKI and C. difficile infection in a dose-dependent manner. Additional days of prophylaxis are not associated with reduced odds of SSI. These findings suggest that stewardship efforts to limit duration have the potential to reduce antimicrobial-associated adverse events without leading to increases in SSI. Disclosures K. Itani, sanofi: Grant Investigator, Grant recipient. Pfizer: Grant Investigator, Grant recipient.

The role of mechanical bowel preparation and oral antibiotics for left-sided laparoscopic and open elective restorative colorectal surgery with and without faecal diversion

There is significant variation in the use of mechanical bowel preparation and oral antibiotics prior to left-sided elective colorectal surgery. There has been no consensus internationally. This was a retrospective analysis of the 2015 American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into four groups: those who had mechanical bowel preparation with oral antibiotics, mechanical bowel preparation alone, oral antibiotics alone and no preparation. The main outcome measures included overall, superficial, deep and organ/space surgical site infections. Secondary outcomes included anastomotic leak, ileus and rate of Clostridium difficile. A total of 5729 patients were included for analysis. The overall surgical site infection rate (any superficial, deep or organ/space infection) was significantly lower in the mechanical bowel preparation and oral antibiotics approach when compared to no preparation (OR = 0.46, 95% CI 0.36-0.59, P < 0.0001). On multivariable logistic regression analysis, mechanical bowel preparation with oral antibiotics maintained a lower risk of overall surgical site infections. MBP and OAB also had a protective effect on anastomotic leak in both the laparoscopic and open cohorts (laparoscopic multivariable adjusted OR = 0.42 (0.19-0.94), P = 0.035; open multivariable adjusted OR = 0.3 (0.12-0.77), P = 0.012). Mechanical bowel preparation alone and oral antibiotics alone was not associated with a significant decrease in surgical site infections. There was no increase in C. difficile occurrences with the use of oral antibiotics. Mechanical bowel preparation with oral antibiotics significantly minimised surgical site infections and anastomotic leak following both laparoscopic and open left-sided restorative colorectal surgery. Mechanical bowel preparation alone did not reduce surgical site infections. There was a trend to reduction in surgical site infections with oral antibiotics alone.

A Protocol to Decrease Surgical Site Infection Rates in Colorectal Surgical Procedures

A Protocol to Decrease Surgical Site Infection Rates in Colorectal Surgical Procedures

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change

BackgroundDespite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates. MethodsBetween 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011–December 31, 2012), implementation (Group B, January 1, 2013–December 31, 2014) and post-implementation (Group C, January 1, 2015–December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI. ResultsAfter the bundle was implemented, there was a significant reduction in superficial (6.6%–4%, p < 0.05), deep (3.7%–1.1%, p < 0.05), and total SSI rates (10.9%–4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%–4.7%, p < 0.05). ConclusionImplementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.

Cesarean Wound Risk Assessment and Management: A Quality Improvement Study [35I

INTRODUCTION: Surgical site infections (SSIs) represent approximately 17% of all hospital-acquired infections with an estimated 500,000 SSIs per year. Cesarean delivery is the primary contributor to SSIs, resulting in patient morbidity and increasing length of hospital stay and medical costs. Studies have shown a benefit to pre-operative antibiotics, but no studies have been done to determine the benefits of stratifying patients into risks categories to tailor management with the goal of preventing infection. METHODS: This is a prospective two-phase quality improvement study in which women undergoing cesarean delivery were categorized according to a risk stratification checklist into high and low-risk groups for developing SSIs. Management for the low risk group consisted of standard pre-operative intravenous antibiotics and a standard pressure dressing. Management for the high risk group consisted of 24 hours of intravenous antibiotics and a specialized Mepilex dressing. SPSS software was used for data analysis. RESULTS: The overall occurrence of SSIs in the low and high risk groups were 7.1% and 3.3% respectively, p-value &lt;0.23. 20% of patients with SSIs had insulin-controlled diabetes, p-value &lt;0.06. Logistic regression demonstrated that both diabetes and BMI were strong predictors of SSIs, p-value &lt;0.01. The incidence of complex SSIs decreased 40% after initiation of the protocol. CONCLUSION: Our data suggest an overall decrease in SSIs after stratifying patients into high and low risk groups with the assigned antibiotics/dressing. Obesity and diabetes are the greatest predictors of SSIs. These risk factors should prompt consideration of use of prolonged antibiotics and a specialized dressing.

Does Vancomycin Powder Decrease Surgical Site Infections in Growing Spine Surgery?: A Preliminary Study.

Vancomycin powder has been demonstrated to be safe in children, and yet there are no data on its use to reduce surgical site infections (SSIs) in surgery for early-onset scoliosis. We performed a retrospective study of our patients treated for early-onset scoliosis in the period of 2010 to 2016. In 2010, we updated our standardized perioperative growing spine care path. The only later change was the gradual introduction of intrawound vancomycin powder. Procedures were categorized into either the control group (without vancomycin powder) or the experimental group (with vancomycin powder), with otherwise identical perioperative management. Initial insertion, revision, and lengthening procedures and final fusions were included. We compared the rate of postoperative SSIs per procedure between the groups. Thirty-six patients who underwent 191 procedures met the inclusion criteria. The clinical and radiographic data were essentially the same between the groups. During the study period, 14 (39%) of the 36 patients developed ≥1 deep SSI. Only 2 patients had multiple acute infections. There were 87 procedures with 12 infections in the control group (SSI rate of 13.8% per procedure), while there were 104 procedures with 5 infections in the vancomycin group (4.8% per procedure). The difference in the SSI rate per procedure was significant (p = 0.038). The number of individual procedures needed to be performed using vancomycin to prevent an SSI was 10.9. The use of vancomycin powder in growing spine surgery for early-onset scoliosis is associated with a significant decreased risk of SSI. It appears to be effective even when previous surgeries have been performed without its use. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

541: Decrease in surgical site infection after cesarean delivery by implementing surgical bundle

541: Decrease in surgical site infection after cesarean delivery by implementing surgical bundle

Impact of International Quality Improvement Collaborative on Congenital Heart Surgery in Pakistan

BackgroundThe International Quality Improvement Collaborative (IQIC) was formed to reduce mortality and morbidity from congenital heart disease (CHD) surgeries in low/middle-income countries.ObjectivesWe conducted this study to compare the postoperative outcomes...

Mo1623 - The Goal of Reaching Zero; How Bundled Interventions Decrease Surgical Site Infections Post Colorectal Surgery: A Meta-Analysis

Mo1623 - The Goal of Reaching Zero; How Bundled Interventions Decrease Surgical Site Infections Post Colorectal Surgery: A Meta-Analysis

The DISINFECT Initiative: Decreasing the Incidence of Surgical INFECTions in Gynecologic Oncology.

Surgical site infections (SSIs) lead to increased patient morbidity and healthcare costs. Our objective was to decrease the SSI rate following gynecologic surgery. Adult patients undergoing abdominal surgery for gynecologic malignancy or benign disease received the following: patient education; preoperative antibacterial soap; appropriate antibiotic prophylaxis; change of gloves and use of clean instruments at surgical closure; surgical dressing for 48h; and a post-discharge phone call. The baseline SSI rate was determined retrospectively (1 April 2014-30 June 2014), while the post-intervention SSI rate was determined prospectively (16 February 2015-15 October 2015). The main outcome was the overall SSI rate with secondary outcomes, including the rate of superficial, deep, incisional and organ space infection, as well as the cost effectiveness of the bundle. A total of 232 baseline and 555 post-intervention patients were included in the study. No differences were observed between the baseline and post-intervention groups with regard to median body mass index (BMI), surgical approach, receipt of preoperative chemotherapy and/or radiation therapy, and cases including bowel surgery. Overall, the SSI rate decreased significantly from baseline [12.5%] to post-intervention [7.4%] (odds ratio [OR] 0.56, 90% confidence interval [CI] 0.37-0.85; p=0.01). A 40% decrease was noted in the rate of superficial and deep infections (9.5 vs. 5.9%; OR 0.60, 90% CI 0.38-0.97; p=0.04) and SSIs after open surgery (21.4 vs. 13.2%; OR 0.56, 90% CI 0.34-0.92; p=0.03). The estimated cost of the intervention was $19.26/case and the net total amount saved during the post-intervention period was $65,625month. This bundled intervention led to a significant decrease in the overall SSI rate and was cost effective. The largest decreases in SSIs were in incisional infections and following open surgery.

Preoperative Patient and Institutional Factors Influence Anaesthetic Type in Foot and Ankle Surgery

Category: Other Introduction/Purpose: Lower-extremity orthopaedic procedures may be performed under regional or general anaesthesia, or a combination of techniques. There is a growing body of evidence outlining benefits of regional anaesthesia, with meta-analyses of randomized controlled trials and registry data suggesting decreases in surgical site infections, thromboembolism, cardiopulmonary complications and length of stay associated with regional anaesthesia. In patients undergoing foot and ankle surgery specifically, the literature demonstrates decreased pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports increased use of regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict anaesthetic type in patients undergoing foot and ankle surgery. Methods: Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analyzed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used. Results: General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p &lt; 0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure ( &lt; 0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 ± 77 minutes, whereas patient provided with regional anaesthesia had a mean length of procedure 83 ± 64 minutes. Conclusion: With increasing evidence supporting use of regional anaesthesia, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure is a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be candidates for regional anaesthesia.