Surgical Site Infection Readmission Research Articles

Utility of Routine Preoperative Urinalysis in the Prevention of Surgical Site Infections

Preoperative assessment is important for neurosurgical risk stratification, but the level of evidence for individual screening tests is low. In preoperative urinalysis (UA), testing may significantly increase costs and lead to inappropriate antibiotic treatment. We prospectively evaluated whether eliminating preoperative UA was noninferior to routine preoperative UA as measured by 30-day readmission for surgical site infection in adult elective neurosurgical procedures. A single-institution prospective, pragmatic study of patients receiving elective neurosurgical procedures from 2018 to 2020 was conducted. Patients were allocated based on same-day versus preoperative admission status. Rates of preoperative UA and subsequent wound infection were measured along with detailed demographic, surgical, and laboratory data. The study included 879 patients. The most common types of surgery were cranial (54.7%), spine (17.4%), and stereotactic/functional (19.5%). No preoperative UA was performed in 315 patients, while 564 underwent UA. Of tested patients, 103 (18.3%) met criteria for suspected urinary tract infection, and 69 (12.2%) received subsequent antibiotic treatment. There were 14 patients readmitted within 30 days (7 without UA [2.2%] vs. 7 with UA [1.2%]) for subsequent wound infection with a risk difference of 0.98% (95% confidence interval-0.89% to 2.85%). The upper limit of the confidence interval exceeded the preselected noninferiority margin of 1%. In this prospective study of preoperative UA for elective neurosurgical procedures using a pragmatic, real-world design, risk of readmission due to surgical site infection was very low across the study cohort, suggesting a limited role of preoperative UA for elective neurosurgical procedures.

Reduction of adverse outcomes from cesarean section by surgical-site infection prevention care bundles in maternity.

To reduce average surgical-site infection (SSI) rates to less than 7.5%, as well as other complications by incrementally implementing an SSI prevention care bundle in maternity: (1) ChloraPrep; (2) PICO dressings, performing elective cesarean sections in a main theater rather than a labor ward and warming blankets; (3) vaginal cleansing; and (4) Hibiscrub. In this prospective cohort study, the association between categorical variables was assessed by χ2 tests, temporal trends in the monthly percentage change of SSI were measured using the Joinpoint Regression Program v4.7.0.0. In all, 1682 women (mean age 33.1± 5.2 years) underwent either elective (53.9%) or emergency (46.1%) cesarean section. After a small initial increase (10.0%-11.8%), SSI progressively declined to 4.4% (χ2 = 22.1, P< 0.001), as did sepsis, reoperation or readmission for SSI: from 12.5% to 0.5% (χ2 = 90.1, P< 0.001). The rates of SSI fell progressively with the cumulative introduction care bundle components. The average monthly percentage change was -14.0% (95% confidence interval -21.8% to -5.4%, P= 0.004), and the average SSI rate was kept below 7.5% for the last 12 months of the study. The maternal SSI prevention care bundle is simple and inexpensive; it effectively reduces SSI after a cesarean section and should be offered routinely to women undergoing cesarean section.

Does surgical approach matter in the treatment of pediatric ulcerative colitis?

BackgroundThis study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes. Materials and methodsThe 2010–2014 Nationwide Readmissions Database was used to identify patients < 18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates. ResultsThere were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (< 2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p<0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs. < 7%, p = 0.017) settings. ConclusionsIn pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.

A guide to caesarean wound healing

A guide to caesarean wound healing

Risk Factors for 30- and 90-Day Readmissions Due To Surgical Site Infection Following Posterior Lumbar Fusion.

This was a retrospective cohort study. Identify the independent risk factors for 30- and 90-day readmission because of surgical site infection (SSI) in patients undergoing elective posterior lumbar fusion (PLF). SSI is a significant cause of morbidity in the 30- and 90-day windows after hospital discharge. There remains a gap in the literature on independent risk factors for readmission because of SSI after PLF procedures. In addition, readmission for SSI after spine surgery beyond the 30-day postoperative period has not been well studied. A retrospective analysis was performed on data from the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. The authors identified 65,121 patients who underwent PLF. There were 191 patients (0.30%) readmitted with a diagnosis of SSI in the 30-day readmission window, and 283 (0.43%) patients readmitted with a diagnosis of SSI in the 90-day window. Baseline patient demographics and medical comorbidities were assessed. Bivariate and multivariate analyses were performed to examine the independent risk factors for readmission because of SSI. In the 30-day window after discharge, this study identified patients with liver disease, uncomplicated diabetes, deficiency anemia, depression, psychosis, renal failure, obesity, and Medicaid or Medicare insurance as higher risk patients for unplanned readmission with a diagnosis of SSI. The study identified the same risk factors in the 90-day window with the addition of diabetes with chronic complications, chronic pulmonary disease, and pulmonary circulation disease. Independent risk factors for readmission because of SSI included liver disease, uncomplicated diabetes, obesity, and Medicaid insurance status. These findings suggest that additional intervention in the perioperative workup for patients with these risk factors may be necessary to lower unplanned readmission because of SSI after PLF surgery.

Interventions Used for Reducing Readmissions for Surgical Site Infections

This article examines what hospitals can do to reduce readmissions for surgical site infections (SSI). Realizing that CMS does not pay the hospital for readmissions due to SSI, strategies must be put into place to reduce the number of readmissions. The analysis here will examine what has been done in the hospital, then, ways to assess each patients risk for SSI upon leaving the hospital. Finally, providing some interventions for reducing SSIs. Introducing the concept of “visiting practitioner.”

Surgical treatment of metastatic spine disease: an update on national trends and clinical outcomes from 2010 to 2014

BACKGROUND CONTEXTMetastatic spine disease (MSD) is becoming more prevalent as medical treatment for cancers advance and extend survival. More MSD patients are treated surgically to maintain neurological function, ambulation, and quality of life. PURPOSEThe purpose of this study was to use a large, nationally representative database to examine the trends, patient outcomes, and health-care resource utilization associated with surgical treatment of MSD. DESIGNThis was an epidemiologic study using national administrative data from the Nationwide Readmissions Database (NRD). PATIENT SAMPLEAll patients in the NRD from 2010 to 2014 who underwent spinal surgery were included in the study. OUTCOME MEASURESMortality, blood transfusion, complications, length of stay, cost, and discharge location during index hospitalization as well as hospital readmission and revision surgery within 90-days of surgery were analyzed. METHODSInternational Classification of Diseases, Ninth Revision, (ICD-9) codes was used to identify patients of interest within the NRD from 2010 to 2014. Patients were separated into two cohorts – those with MSD and those without. Trends for surgical treatment of MSD were assessed and outcomes measures for both cohorts were analyzed and compared. RESULTSThe number of surgical treatments for MSD increased from 6,007 in 2010 to 7,032 in 2014 (p-trend<.0001) which represented a 17.1% increase. During index hospitalization, MSD patients had an increased risk of mortality (odds ratio [OR]=3.22, 95% confidence interval [CI]: 2.85–3.63, p<.0001), blood transfusion (OR=2.93, 95% CI: 2.66–3.23, p<.0001), any complication (OR=1.24, 95% CI: 1.18–1.31, p<.0001), and discharge to skilled nursing facility (OR=1.51, 95% CI:1.41–1.61, p<.0001). MSD patients had longer average length of stay (13.05 vs. 4.56 days, p<.0001) and cost ($49,421.75 vs. $26,190.37, p<.0001) during index hospitalization. Furthermore, MSD patients had an increased risk of hospital readmission (OR=2.82, 95% CI: 2.68–2.96, p<.0001), readmission for surgical site infection (OR=2.38, 95% CI: 2.20–2.58, p<.0001), and readmission with neurologic deficits (OR=1.62, 95% CI: 1.27–2.06, p<.0001) despite a decreased risk of revision fusion (OR=0.71, 95% CI: 0.53–0.96, p=.026). CONCLUSIONSThe number of MSD patients who undergo surgical treatments is increasing. Not only do these patients have worse outcomes during index hospitalization, but they are also at an increased risk of hospital readmission for surgical site infection and neurologic complications. These findings stress the need for multidisciplinary perioperative treatment plans that mitigate risks and facilitate quick, effective recovery in these unique, at-risk patients.

Does public report card matter? A 10-year interrupted time series analysis on total knee replacement.

There is a lack of evidence that shows whether a report card can improve health outcomes in terms of infection rates or unscheduled readmission by using rigorous methods to evaluate its impact. We used the National Health Insurance Administration's claims database from 1 January 2004 to 30 December 2013 and a time series analysis to evaluate the impact of the quality report card initiative on three negative outcomes of total knee replacement for each quarter of the year, including the rates of superficial infection of a knee replacement, deep infection of knee arthroplasty and unplanned readmissions for surgical site infection. These negative outcomes (original scale) do not show significant decreases in terms of superficial infection (-0.05‰, -0.63 to 0.53‰, P = 0.87), deep infection (-0.003‰, -0.19 to 0.18‰, P = 0.97) and unscheduled readmission (0.02‰, -0.21 to 0.25‰, P = 0.88). The total knee replacement public report card initiative did not improve the rate of infection and unscheduled readmission for surgical site infection. This report card in Taiwan should involve physicians' participation in the design and be tailored to be suitable for reading by patients in order to further enhance the chance of improvement in these negative outcomes.

Retrospective analysis of the Photo at Discharge scheme and readmission for surgical site infection following coronary artery bypass graft surgery.

Surgical site infection (SSI) is a costly and devastating complication of surgery. Many cardiac SSIs develop after the patient leaves hospital, but evidence demonstrating the benefit of patient/carer involvement in the process of monitoring and promptly identifying SSI post-discharge is limited. This study estimates the probability of readmission for SSI for coronary artery bypass graft (CABG) patients receiving the Photo at Discharge (PaD). Trained personnel undertook continuous, prospective SSI surveillance using Public Health England protocol between January 2013 and December 2016. Baseline covariables were collected for 1747 CABG-only procedures. As a quasi-randomised design, we adjusted for non-random PaD assignment using retrospective propensity score (PS)-matching based on 12 variables of interest, assessed whether the model had been adequately specified and performed an outcomes analysis. A total of 568 patients with PaD were PS-matched with 568 controls. The probabilities of SSI readmission were 0.352 (2/568) and 1.761 (10/568), respectively. The difference in risk of readmission for SSI was significant (relative risk = 0.2, 95% confidence interval = 0.04-0.91; P = 0.04). Findings from this single-centre observation study suggest the PaD is associated with a reduction in CABG readmission for SSI and a further study is warranted to verify the efficacy of this strategy.

Readmissions for surgical site infections following caesarean section.

This retrospective study was conducted to identify the incidence and characteristics associated with readmissions for surgical site infections following caesarean section in a tertiary hospital from 2012 to 2015. Of 6334 patients who underwent caesarean section, 165 (2.6%) were readmitted, most commonly for surgical site infection (25.5%, n=42). Thirty-seven of these patients (88%) had an emergency caesarean compared to five (12%) following an elective caesarean section. Of the women with surgical site infections, 69% were overweight and 14% had diabetes. Emergency caesarean sections were responsible for the majority of readmissions, particularly in women with co-morbidities that predisposed them to infection.

Evaluation of hospital readmissions for surgical site infections in Italy.

The objectives of this investigation are to assess the prevalence of hospital readmissions for surgical site infections (SSIs) in patients aged ≥18 in Italy and to describe the clinical characteristics of these patients and evaluate the possible association with readmission for SSIs. A retrospective epidemiological study was conducted between January and May 2015 considering a sample of patients aged ≥18 years admitted to the surgical wards of two hospitals in Naples and undergoing surgery in the year 2014. 3.8% of patients had been readmitted and 28.8% of them were readmitted to hospital due to SSIs. The multiple logistic regression model showed that readmissions for SSIs were significantly more common in smokers (odds ratio [OR] = 3.14; 95% confidence interval [CI] = 1.13-8.69), in patients with immunosuppression status (OR = 8.28; 95% CI = 1.76-38.87), in patients with low serum albumin (OR = 3.07; 95% CI = 1.05-9.01) and in patients who had undergone a surgical procedure classified as contaminated (OR = 10:44; 95% CI = 3.11-35.01) compared with those that had undergone a surgical procedure classified as clean. The results point to the need that hospital infection prevention strategies are implemented in order to reduce morbidity and mortality for patients. Moreover, the measures taken to prevent infections would lead to a reduction in health spending since almost one third of readmissions to the hospital in our study were due to SSIs.

Is enhanced recovery enough for reducing 30-d readmissions after surgery?

BackgroundFew enhanced recovery pathways (ERPs) include processes related to the hospital to home transfer. Little has been reported regarding readmissions in enhanced recovery programs. This study evaluates readmissions and identifies areas to optimize ERPs to prevent readmissions. MethodsWe conducted an observational, retrospective study at a single tertiary care center. Patients in an ERP for colorectal surgery were compared with a similar cohort who underwent surgery before protocol implementation. We evaluated 30-d readmission, compliance to enhanced recovery protocol, and diagnoses and patient care experiences related to transition of care. ResultsReadmission rates (17.6% versus 19.4%; P = 0.55) were similar. There was significant reduction in index hospitalization length of stay (5.3 versus 7.0 d; P < 0.001) and postoperative surgical site infection (7.3% versus 16.6%; P = 0.01). Although enhanced recovery was associated with reduced readmissions for surgical site infections (31% versus 50.7%, P = 0.02), there was a trend toward increased readmissions for small bowel obstruction–ileus (31% versus 19.1%, P = 0.13). ERPs did not impact perceptions of care transitions; however, those who were readmitted rated their transition lower than those that were not. ConclusionsAlthough ERPs did not reduce readmissions, the program was associated with reduced length of stay and surgical site infections. ERPs did not influence perceptions of the transition to home. Transition process measures aimed at reducing readmission and improving patient outcomes, including use of transition guides, remote vital sign and symptom monitoring, and early clinical follow-up have not traditionally been part of ERP protocols but should be considered.

Abstract: “I Can’t Believe You’re Back:” Expanded 30-day Readmissions After Plastic Surgery

INTRODUCTION: Hospitals are working to reduce 30-day readmissions, driven by financial and quality incentives previously affecting only medical conditions but now affecting surgical procedures relevant to plastic surgeons;1 however, little is known about the reasons for readmission.2,3 METHODS: Patients who underwent surgery by plastic surgeons were identified from the 2012–2013 National Surgical Quality Improvement Program database. Readmission characteristics following 14 types of plastic surgery procedures were divided into 11 groups and compared across procedure types. RESULTS: Plastic surgery identified procedure codes yielded 31,561 patients. Of these, 1,162 experienced a 30-day all-cause readmission (3.7%). Most readmissions were unplanned at time of discharge (1,064, 91.6%). The majority of unplanned readmissions were directly related to the index hospital procedure (879, 75.6%), producing a gross 2.8% rate of unplanned readmissions related to plastic surgery procedures. The highest readmission rate (9.6%) was associated with free flaps for non-breast reconstruction; the lowest rates of 0% and 1.7% were after gynecomastia and hand/nerve surgery, respectively. Importantly, 61.9% of readmissions were for wound problems: infections (45.2% of unplanned readmissions related to index procedure, 1.2% absolute rate) or other wound complications (16.7%, 0.5%); few were readmitted for pain (1.8%, 0.1%) or bleeding (2.3%, 0.1%), although notably almost half (45.0%) of all readmissions for bleeding came after panniculectomy/abdominoplasty. Readmissions for venous thromboembolic disease were seen across all procedures except gynecomastia (n=125) and craniofacial surgery (n=832), but all were <1.0% and most were <0.5%. When all procedures were examined together no clustering of readmission timing was seen; patients were readmitted evenly throughout the 30-day postoperative period; however analyses within individual complications showed variability: readmissions for bleeding or hemorrhage most often occurred within the first week, while readmissions for surgical site infections more commonly began a few days after the procedure and continued throughout the 30-day post-op period. CONCLUSION: Readmission after plastic surgery remains low, with substantial variance among procedure types. Readmission most commonly (over 60%) results from wound complications. These findings can assist surgeons and health systems to tailor preoperative risk counseling and postoperative discharge services for patients planning to undergo various types of plastic surgery procedures. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. QualityNet. Overview: Readmission Measures: Publicly reported risk-standardized, 30-day readmission measures for AMI, HF, PN, HWR, and THA/TKA. QualityNetwebsite. http://www.qualitynet.org/dcs/ContentServer?pagename=QnetPublic%2FPage%2FQnetTier3&cid=1219069855273. Accessed June 7, 2016 2. Merkow RP, Mila HJ, Jeanette WC, et al. 2015. “Underlying reasons associated with hospital readmission following surgery in the United States.” JAMA;313(5):483–495 3. Tahiri Y, Fischer JP, Wink JD, et al. Analysis of risk factors associated with 30-day readmissions following pediatric plastic surgery: a review of 5376 procedures. Plast Reconstr Surg. 2015;135(2):521–529

Quantifying Excess Cost Associated with Readmission for Surgical Site Infection Following Open Vascular Procedures Involving the Lower Extremity

Quantifying Excess Cost Associated with Readmission for Surgical Site Infection Following Open Vascular Procedures Involving the Lower Extremity

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.