Post-discharge Surveillance Research Articles

A benchmark too far: findings from a national survey of surgical site infection surveillance

The national surgical site infection (SSI) surveillance service in England collates and publishes SSI rates that are used for benchmarking and to identify the prevalence of SSIs. However, research studies using high-quality SSI surveillance report rates that are much higher than those published by the national surveillance service. This variance questions the validity of data collected through the national service. To audit SSI definitions and data collection methods used by hospital trusts in England. All 156 hospital trusts in England were sent questionnaires that focused on aspects of SSI definitions and data collection methods. Completed questionnaires were received from 106 hospital trusts. There were considerable differences in data collection methods and data quality that caused wide variation in reported SSI rates. For example, the SSI rate for knee replacement surgery was 4.1% for trusts that used high-quality postdischarge surveillance (PDS) and 1.5% for trusts that used low-quality PDS. Contrary to national protocols and definitions, 10% of trusts did not provide data on superficial infections, 15% of trusts did not use the recommended SSI definition, and 8% of trusts used inpatient data alone. Thirty trusts did not submit a complete set of their data to the national surveillance service. Unsubmitted data included non-mandatory data, PDS data and continuous data. The national surveillance service underestimates the prevalence of SSIs and is not appropriate for benchmarking. Hospitals that conduct high-quality SSI surveillance will be penalized within the current surveillance service.

Methodology of the Norwegian Surveillance System for Healthcare-Associated Infections: The value of a mandatory system, automated data collection, and active postdischarge surveillance

Surveillance is a primary component of systems for the prevention of health care-associated infections (HCAI). Feedback to surgeons from these surveillance systems may reduce rates of surgical site infections (SSIs) by approximately 20%. Our objective was to describe the Norwegian Surveillance System for Healthcare-Associated Infections' (NOIS) module for SSI (NOIS-SSI) and to evaluate the completeness of hospital participation, the effectiveness of automated data collection, and the added value of follow-up after hospital discharge during 2005 to2009. NOIS was introduced by regulation in 2005. Hospital participation is described through adherence to the mandatory requirements and participation in the voluntary aspects of the system. Automated data collection is evaluated through the completeness of reporting of explanatory and administrative variables. The impact of active postdischarge surveillance is assessed through the completeness of follow-up and the proportion of infections detected after hospital discharge. The system has achieved 95% (52/55) hospital participation, with 65% (34/52) of the hospitals submitting more data than the required minimum. The completeness of patient and procedure-related background data is satisfactory, with 23.3% (5,079/21,772) of the records having at least 1 missing value. The completeness of 30-day follow-up of patients is 90.7% (19,747/21,772), and 81% (765/948) of the infections were detected after discharge from hospital. Implementation of a new surveillance system for SSI has been successful evaluated through hospital participation, the completeness of reporting of explanatory and administrative variables, and the completeness of postdischarge follow-up. Important success factors are a mandatory system, automated data-harvesting systems in hospitals, and active postdischarge surveillance.

Postdischarge surveillance following delivery: The incidence of infections and associated factors

To assess the effectiveness of a postdischarge surveillance system to reveal cases of postpartum infections that could be missed by the current in-hospital routine surveillance and to identify predictors of postpartum infections. The prospective surveillance included obstetrics patients. The information recorded included sociodemographic characteristics, infection-predisposing conditions, documentation of extrinsic risk factors, variables related to pregnancy and delivery, and variables related to each patient's newborn. A telephone interview on Day 30 after hospital discharge was performed to retrieve information related to signs and symptoms of infection. One thousand seven hundred five patients agreed to participate for a response rate of 93%. One hundred forty-nine (8.9%) patients contacted by telephone reported at least 1 episode of infection within 30 days of discharge. There were 24 infections occurring during hospitalization, representing only 16.1% of all infections. There was an increased risk of postpartum infections in women with complications during labor, in those who had a caesarean delivery, and in those who reported alcohol consumption during pregnancy. Our study demonstrated the need for implementing postdischarge surveillance programs for obstetrics patients that also identify infections following vaginal delivery. Postdischarge surveillance by telephone contact proved to be a feasible and effective method.

Patient narratives of surgical site infection: implications for practice

Exploring patients' experiences has been used widely within healthcare to improve clinical service delivery. To date there has been minimal patient input of this kind into aspects of surgical site infection (SSI), such as surveillance or prevention interventions. To obtain information from patients' experiences of SSIs to improve clinical practice. Narrative interviews with 17 patients with SSIs (four deep, 12 organ space and one superficial) from three hospitals in England were conducted followed by thematic content analysis. Patients lacked overall awareness, concern and understanding of SSIs. Seven patients did not know that they had SSIs and, judging from patients' accounts, staff may have contributed to the lack of awareness by not informing patients of SSIs or downplaying their existence. The use of primary care resources was considerable and six of the patients were absent from work for two to four months. SSIs have a low profile among patients which, if it were raised, could increase compliance with preventive interventions. This study confirms the appropriateness of using patient self-assessment post-discharge surveillance questionnaires to identify SSI symptoms, and highlights the need to identify total costings including to primary care, patients and the economy.

Surgical site infection surveillance: a Scottish perspective (2003–2010)

Health Protection Scotland facilitates national surveillance of surgical site infection (SSI) in Scotland with all hospitals participating in the SSI programme. For the period January 2003 to December 2010, there were 1883 inpatient SSIs, resulting from 192,007 procedures in the selected surgical categories. The inpatient SSI incidence density rates in Scotland over the duration of the SSI surveillance programme (2003–2010) showed a reduction over the eight years of surveillance for all procedures, with a significant reduction in caesarean section, hip arthroplasty, knee arthroplasty, and open reduction of long bone fracture. For all procedures, the highest proportion of SSIs detected were superficial. Data from Scotland includes information on infections occurring post-discharge from hospitals, which is an increasingly important aspect of monitoring, as length of stay in hospital is reducing over time. The introduction of readmission surveillance until day 30 post-operatively for hip arthroplasty in 2007 and post-discharge surveillance (PDS) to day 10 for caesarean section in 2009 has resulted in a higher proportion of SSIs being detected following discharge from hospital.

W056 SURGICAL SITE INFECTIONS FOLLOWING CESAREAN SECTION: PROSPECTIVE INPATIENT AND POST-DISCHARGE SURVEILLANCE IN A CANADIAN HOSPITAL

International Journal of Gynecology & ObstetricsVolume 119, Issue S3 p. S723-S723 Poster presentations W056 SURGICAL SITE INFECTIONS FOLLOWING CESAREAN SECTION: PROSPECTIVE INPATIENT AND POST-DISCHARGE SURVEILLANCE IN A CANADIAN HOSPITAL W. Ng, W. NgSearch for more papers by this authorA.R.H. Brown, A.R.H. BrownSearch for more papers by this authorD. Alexander, D. AlexanderSearch for more papers by this authorM.F. Ho, M.F. HoSearch for more papers by this authorB. Kerr, B. KerrSearch for more papers by this authorM. Amato, M. AmatoSearch for more papers by this authorK. Katz, K. KatzSearch for more papers by this author W. Ng, W. NgSearch for more papers by this authorA.R.H. Brown, A.R.H. BrownSearch for more papers by this authorD. Alexander, D. AlexanderSearch for more papers by this authorM.F. Ho, M.F. HoSearch for more papers by this authorB. Kerr, B. KerrSearch for more papers by this authorM. Amato, M. AmatoSearch for more papers by this authorK. Katz, K. KatzSearch for more papers by this author First published: 22 October 2012 https://doi.org/10.1016/S0020-7292(12)61782-2Citations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume119, IssueS3Abstracts of XX FIGO World Congress of Gynecology and ObstetricsOctober 2012Pages S723-S723 RelatedInformation

Prevalence and predictors of wound infection in elective clean and clean/contaminated surgery in Khartoum Teaching Hospital, Sudan

Background: Surgical site infections are the second most common cause of hospital acquired infections. The objectives of this study were to quantify the rate of wound infection and to identify risk factors associated for its prevalence among patients admitted for elective surgery in Khartoum Teaching Hospital in Sudan. A prospective study was conducted. All patients, aged >18 years admitted during March 1st 2010 to 31th October 2010 were recruited. Baseline data was collected before patient's operations on. Patients were followed up to one month for detection of wound infection using bedside and post-discharge surveillance. A total of 1387 patients were included with a mean age of 35±14 years. 1138(82%) were females. More than three quarters were healthy (79.3%) and 1367(98.6%) patients were operated on conventionally. The total number of the performed surgical procedures was 1426. The rate of wound infection was found to be 9%. Univariate analysis revealed that five variables were significantly associated with the prevalence of wound infection; namely patient’s body mass index (P=0.041), co-morbidity (P=0.006), presence of diabetes (P=0.010), ASA score (P=0.000) and surgical technique (P=0.007). Multivariate logistic analysis showed that ASA score 2 and ASA score > 3, {adjusted OR, 1.9 (1.2-3.0), P =0.006 and adjusted OR, 3.6 (2.0-6.7); P<0.001 respectively}, laparoscopic surgical technique {adjusted OR, 5.5 (2-14.8); P=0.001} were mostly significantly associated with the prevalence of wound infection. The rate of wound infection was high with patient’s physical status and use of the laparoscope technique being strong predictors of infection.

784 Impact of Elevated Preoperative Hemoglobin A1C, Intensive Diabetes Management, and Targeted Wound Surveillance on the Incidence of Post-Discharge Surgical Site Infections Following Cardiac Surgery

784 Impact of Elevated Preoperative Hemoglobin A1C, Intensive Diabetes Management, and Targeted Wound Surveillance on the Incidence of Post-Discharge Surgical Site Infections Following Cardiac Surgery

Recommendations for surveillance priorities for healthcare-associated infections and criteria for their conduct

Surveillance and feedback of results to clinical teams is central to performance improvement in managing healthcare-acquired infections. A major role of the Advisory Committee on Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) is to advise on surveillance priorities. A sub-committee was set up to systematically review existing UK surveillance schemes. The following three systems were examined in detail: mandatory reporting of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and Clostridium difficile infection to the HPA; surveillance of surgical site infection undertaken by the HPA; and surgical site infection surveillance undertaken at University College London Hospital. Recommendations included the extension of mandatory reporting to include bacteraemia due to Escherichia coli and methicillin-susceptible S. aureus (MSSA), post-discharge surveillance of surgical site infection, the need for validation of surveillance systems and mandatory reporting of Caesarean section wound infections. Mandatory reporting of bacteraemia due to E. coli and MSSA were introduced during 2011 and further extension of surveillance is likely.

Vigilância de infecção de sítio cirúrgico pós-alta hospitalar em hospital de ensino do Distrito Federal, Brasil: estudo descritivo retrospectivo no período 2005-2010

Objective: this study investigated the occurrence of surgical site infection (SSI) and characteristics of cases among patients served under the program of post-discharge surveillance of the General Surgery Teaching Hospital of Brasilia, Federal District, Brazil. Methods: the retrospective descriptive study, from 2005-2010, used data obtained by consulting hospital information systems, patients records, and records of results of microbiological tests. Results: during the study period, 4,098 were treated and 82.2% of them attended by the follow-up program. From 4,375 surgeries evaluated, (3.4%) 147 cases of SSI were diagnosed; Staphylococcus aureus was predominant among the 19 species isolated in cultures of the surgical site; a higher incidence of SSI occurred between the 6th and the 10th postoperative day. Conclusion: this study showed the importance of ambulatory accompaniment in reducing underreporting and its consequent contribution to the validity of indicators and in improving the surveillance of SSI in the health services.

Streamlined Emergency Department Post-Discharge Surveillance Reduces Rehospitalizations

Background/Objectives: This Presentation looks into the daily surveillance of positive cultures in the emergency department setting. Previous to this program the inconsistancy in which positive cultures was addressed and antibiotic stewardship was seen showed a large number of patients being placed on the incorrect antibiotic for their positive culture result as well as the lack of follow up by the hospital post discharge. it also addresses rehospitalizations related to these unaddressed issues.

The Impact of Depth of Infection and Postdischarge Surveillance on Rate of Surgical-Site Infections in a Network of Community Hospitals

To describe the epidemiology of surgical-site infections (SSIs) in community hospitals and to explore the impact of depth of SSI, healthcare location at the time of diagnosis, and variations in surveillance practices on the overall rate of SSI. Retrospective cohort study. Thirty-seven community hospitals in the southeastern United States. Consecutive sample of patients undergoing surgical procedures between July 1, 2007, and December 31, 2008. ANOVA was used to compare rates of SSIs, and the F test was used to compare the distribution of rates of SSIs. Wilcoxon Signed Rank test [corrected] was used to test for differences in performance rankings of hospitals. Following 177,706 surgical procedures, 1,919 SSIs were identified (incidence, 1.08 per 100 procedures). Sixty-four percent (1,223 of 1,919) of these were identified as complex SSIs; 87% of the complex SSIs were diagnosed in inpatient settings. The median proportion of superficial-incisional SSIs was 37% (interquartile range, 29.6%-49.5%). Postdischarge SSI surveillance was variable, with 58% of responding hospitals using surgeon letters. As reporting focus was narrowed from all SSIs to complex SSIs (incidence, 0.69 per 100 procedures) and, finally, to complex SSIs diagnosed in the inpatient setting (incidence, 0.51 per 100 procedures), variance in rates changed significantly ([Formula: see text]). Performance ranking of individual hospitals, based on rates of SSIs, differed significantly, depending on the reporting method utilized ([Formula: see text]). Inconsistent reporting methods focused on variable depths of infection and healthcare location at time of diagnosis significantly impact rates of SSI, distribution of rates of SSI, and hospital comparative-performance rankings. We believe that public reporting of SSI rates should be limited to complex SSIs diagnosed in the inpatient setting.

Performance, Revision, and Extension of the National Nosocomial Infections Surveillance System's Risk Index in Brazilian Hospitals

To assess the benefit of using procedure-specific alternative cutoff points for National Nosocomial Infections Surveillance (NNIS) risk index variables and of extending surgical site infection (SSI) risk prediction models with a postdischarge surveillance indicator. Open, retrospective, validation cohort study. Five private, nonuniversity Brazilian hospitals. Consecutive inpatients operated on between January 1993 and May 2006 (other operations of the genitourinary system [n = 20,723], integumentary system [n = 12,408], or musculoskeletal system [n = 15,714] and abdominal hysterectomy [n = 11,847]). For each procedure category, development and validation samples were defined nonrandomly. In the development samples, alternative SSI prognostic scores were constructed using logistic regression: (i) alternative NNIS scores used NNIS risk index covariates and cutoff points but locally derived SSI risk strata and rates, (ii) revised scores used procedure-specific alternative cutoff points, and (iii) extended scores expanded revised scores with a postdischarge surveillance indicator. Performances were compared in the validation samples using calibration, discrimination, and overall performance measures. The NNIS risk index showed low discrimination, inadequate calibration, and predictions with high variability. The most consistent advantage of alternative NNIS scores was regarding calibration (prevalence and dispersion components). Revised scores performed slightly better than the NNIS risk index for most procedures and measures, mainly in calibration. Extended scores clearly performed better than the NNIS risk index, irrespective of the measure or operative procedure. Locally derived SSI risk strata and rates improved the NNIS risk index's calibration. Alternative cutoff points further improved the specification of the intrinsic SSI risk component. Controlling for incomplete postdischarge SSI surveillance provided consistently more accurate SSI risk adjustment.

Outcomes of extremely low birth weight infants with bronchopulmonary dysplasia: Impact of the physiologic definition

AimsWe compared neurodevelopmental outcomes of extremely low birth weight (ELBW) infants with and without bronchopulmonary dysplasia (BPD), using the physiologic definition. Study designELBW (birth weights<1000g) infants admitted to the Neonatal Research Network centers and hospitalized at 36weeks postmenstrual age (n=1189) were classified using the physiologic definition of BPD. Infants underwent Bayley III assessment at 18–22months corrected age. Multivariable logistic regression was used to determine the association between physiologic BPD and cognitive impairment (score<70). ResultsBPD by the physiologic definition was diagnosed in 603 (52%) infants, 537 of whom were mechanically ventilated or on FiO2>30% and 66 who failed the room air challenge. Infants on room air (n=505) and those who passed the room air challenge (n=51) were classified as “no BPD” (n=556). At follow up, infants with BPD had significantly lower mean weight and head circumference. Moderate to severe cerebral palsy (7 vs. 2.1%) and spastic diplegia (7.8 vs. 4.1%) and quadriplegia (3.9 vs. 0.9%) phenotypes as well as cognitive (12.8 vs. 4.6%) and language scores<70 (24.2 vs. 12.3%) were significantly more frequent in those with BPD compared to those without BPD. BPD was independently associated (adjusted OR 2.4; 95% CI 1.40–4.13) with cognitive impairment. ConclusionsRates of adverse neurodevelopmental outcomes in early childhood were significantly higher in those with BPD. BPD by the physiologic definition was independently associated with cognitive impairment using Bayley Scales III. These findings have implications for targeted post-discharge surveillance and early intervention.

Postdischarge Surgical Site Infection Surveillance Practices in Washington Acute Care Hospitals

Little is known about postdischarge surveillance practices currently in place among American hospitals. This survey describes practices used by acute care hospitals covered by Washington State's legislated mandate for public reporting of surgical site infections. While the vast majority of facilities use multiple techniques, wide variation in practices was discovered.

Randomized Trial of Antimicrobial-Coated Sutures To Prevent Surgical Site Infection after Breast Cancer Surgery

Surgical site infection (SSI) is the fourth commonest healthcare-associated infection and complicates at least 5% of open operations. In a randomized clinical trial, antimicrobial-coated sutures were compared with their conventional counterparts, polyglactin and poliglecaprone, for skin closure after breast cancer surgery to assess their role in reducing the rate of SSI. Between November 2008 and February 2011, 150 female patients presenting with breast cancer to a single center were randomized to skin closure with antimicrobial-coated or plain sutures. Postoperatively, SSI was defined using the U.S. Centers for Disease Control and Prevention (CDC) definitions and scored using the ASEPSIS or Southampton systems by trained, blinded observers with close post-discharge surveillance and patient diaries. Surgeons and patients were blinded to the type of suture used. Using CDC criteria, the overall rate of SSI was 18.9% at six weeks. Six patients (4.7%) needed intervention or readmission for SSI. Skin closure with antimicrobial sutures showed a non-statistically significant reduction in the SSI rate, to 15.2%, compared with conventional sutures (22.9%). A uniform tendency for fewer SSIs in the antimicrobial-coated suture group was found using ASEPSIS and Southampton scores, but again, the difference was not statistically significant. The previously reported high rate of SSI related to breast surgery was confirmed. Using statistical modeling and earlier reports, the study was powered to show a difference using ASEPSIS scores, but the modification used in this trial failed to find a difference. Finding a statistically significant difference would have needed two to three times the number of patients recruited. Further evaluation of antimicrobial-coated sutures is merited, particularly if used as part of a care bundle to reduce SSI after breast cancer surgery.

A novel method of surgical site infection surveillance after cardiac surgery by active participation of stake holders

We describe a comprehensive surveillance system involving infection control practitioners, surgeons, administrative staff, and patients aimed at improving the postdischarge surveillance of surgical site infections. The system was able to detect 22 infections out of 538 procedures, 95% of which were detected during the postdischarge period.

Identification of risk factors by systematic review and development of risk-adjusted models for surgical site infection.

Surgical site infections (SSIs) are complications of surgery that cause significant postoperative morbidity. SSI has been proposed as a potential indicator of the quality of care in the context of clinical governance and monitoring of the performance of NHS organisations against targets. We aimed to address a number of objectives. Firstly, identify risk factors for SSI, criteria for stratifying surgical procedures and evidence about the importance of postdischarge surveillance (PDS). Secondly, test the importance of risk factors for SSI in surveillance databases and investigate interactions between risk factors. Thirdly, investigate and validate different definitions of SSI. Lastly, develop models for making risk-adjusted comparisons between hospitals. A single hospital surveillance database was used to address objectives 2 and 3 and the UK Surgical Site Infection Surveillance Service database to address objective 4. There were four elements to the research: (1) systematic reviews of risk factors for SSI (two reviewers assessed titles and abstracts of studies identified by the search strategy and the quality of studies was assessed using the Newcastle Ottawa Scale); (2) assessment of agreement between four SSI definitions; (3) validation of definitions of SSI, quantifying their ability to predict clinical outcomes; and (4) development of operation-specific risk models for SSI, with hospitals fitted as random effects. Reviews of SSI risk factors other than established SSI risk indices identified other risk; some were operation specific, but others applied to multiple operations. The factor most commonly identified was duration of preoperative hospital stay. The review of PDS for SSI confirmed the need for PDS if SSIs are to be compared meaningfully over time within an institution. There was wide variation in SSI rate (SSI%) using different definitions. Over twice as many wounds were classified as infected by one definition only as were classified as infected by both. Different SSI definitions also classified different wounds as being infected. The two most established SSI definitions had broadly similar ability to predict the chosen clinical outcomes. This finding is paradoxical given the poor agreement between definitions. Elements of each definition not common to both may be important in predicting clinical outcomes or outcomes may depend on only a subset of elements which are common to both. Risk factors fitted in multivariable models and their effects, including age and gender, varied by surgical procedure. Operative duration was an important risk factor for all operations, except for hip replacement. Wound class was included least often because some wound classes were not applicable to all operations or were combined because of small numbers. The American Association of Anesthesiologists class was a consistent risk factor for most operations. The research literature does not allow surgery-specific or generic risk factors to be defined. SSI definitions varied between surveillance programmes and potentially between hospitals. Different definitions do not have good agreement, but the definitions have similar ability to predict outcomes influenced by SSI. Associations between components of the National Nosocomial Infections Surveillance risk index and odds of SSI varied for different surgical procedures. There was no evidence for effect modification by hospital. Estimates of SSI% should be disseminated within institutions to inform infection control. Estimates of SSI% across institutions or countries should be interpreted cautiously and should not be assumed to reflect quality of medical care. Future research should focus on developing an SSI definition that has satisfactory psychometric properties, that can be applied in everyday clinical settings, includes PDS and is formulated to detect SSIs that are important to patients or health services. The National Institute for Health Research Technology Assessment programme.

Impact of method and duration of post discharge surveillance on detection of surgical site infections

Since surgical site infections (SSIs) arise before and after discharge from the hospital, post discharge surveillance (PDS) of SSIs is inevitable for proper surveillance. Two methods of PDS are recommended by the Dutch surveillance network (PREZIES). Duration of PDS normally is 30 days or 1 year after surgery for implant-free and implant surgery respectively. We compare cumulative SSI rates over time for “recommended PDS” and “other PDS-methods”, and investigate whether the advised duration of PDS is justifiable.

Surgical-site infection indices detected by post-discharge surveillance in a medium sized hospital in the city of São Paulo, Brazil

Surgical-site infections (SSI) account for about 24% of hospital infections. Due to short postoperative staying, SSI diagnosis is eventually made after discharge. SSI rates may be under reported; therefore surveillance after discharge is needed to obtain reliable indices of SSI and to improve quality of care. Aim: To describe the SSI rate assessed after discharge and to compare post-discharge rates to intra hospital rates.