Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals

Background

A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation.

Methods

A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated.

Results

Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%–90% of respondents, but less than 50% stated that these strategies were in place at their institutions.

Conclusion

Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.     

Blood Utilization After Primary Total Joint Arthroplasty in a Large Hospital Network

Background

Since a study in orthopedic hip fracture patients demonstrated that a liberal hemoglobin (Hb) threshold does not improve patient morbidity and mortality relative to a restrictive Hb threshold, the standard of care in total joint arthroplasty (TJA) should be examined to understand the variability of red blood cell (RBC) transfusion following TJA.

Questions/purposes

The study aimed to answer the following questions: (1) What is the blood utilization rate after primary TJA for individual surgeons within a large hospital network? (2) What is the comparison of hospital charges, length of stay (LOS), and discharge locations among TJA patients who were and were not transfused?

Methods

A retrospective study was conducted on 3,750 primary total knee arthroplasties (TKAs) and 2,070 primary total hip arthroplasties (THAs), and data was retrospectively collected over a 15-month period on the number of RBCs transfused per patient, along with demographic and cost details. The number of patients who received at least 1 RBC unit and the number of RBCs transfused per patient was calculated and stratified by surgeon.

Results

In the postoperative period, 19.3% TKA patients and 38.5% THA patients received a RBC transfusion. Transfusion rates following TJA varied widely between surgeons (TKA 4.8–63.8%, THA 4.3–86.8%). Transfused TKA patients received an average of 1.65 ± 0.03 RBCs, and THA patients received an average of 1.97 ± 0.14 RBCs. LOS and hospital charges for blood transfusion patients were higher than nontransfused patients.

Conclusion

Blood utilization after primary TJA varies greatly among surgeons, suggesting that resources may be misallocated. These findings highlight the need to standardize RBC transfusion practice following TJA.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9327-y) contains supplementary material, which is available to authorized users.     

High Efficiency Particulate Air Filters Do Not Affect Acute Infection Rates During Primary Total Joint Arthroplasty Using Forced Air Warmers

Background

Studies have suggested that forced-air warmers (FAWs) increase contamination of the surgical site. In response, FAWs with high efficiency particulate air filters (FAW-HEPA) were introduced. This study compared infection rates following primary total joint arthroplasty (TJA) using FAW and FAW-HEPA.

Feasibility and Acceptance of a Robotic Surgery Ergonomic Training Program

Background and Objectives:

Assessment of ergonomic strain during robotic surgery indicates there is a need for intervention. However, limited data exist detailing the feasibility and acceptance of ergonomic training (ET) for robotic surgeons. This prospective, observational pilot study evaluates the implementation of an evidence-based ET module.

Methods:

A two-part survey was conducted. The first survey assessed robotic strain using the Nordic Musculoskeletal Questionnaire (NMQ). Participants were given the option to participate in either an online or an in-person ET session. The ET was derived from Occupational Safety and Health Administration guidelines and developed by a human factors engineer experienced with health care ergonomics. After ET, a follow-up survey including the NMQ and an assessment of the ET were completed.

Results:

The survey was sent to 67 robotic surgeons. Forty-two (62.7%) responded, including 18 residents, 8 fellows, and 16 attending physicians. Forty-five percent experienced strain resulting from performing robotic surgery and 26.3% reported persistent strain. Only 16.6% of surgeons reported prior ET in robotic surgery. Thirty-five (78%) surgeons elected to have in-person ET, which was successfully arranged for 32 surgeons (91.4%). Thirty-seven surgeons (88.1%) completed the follow-up survey. All surgeons participating in the in-person ET found it helpful and felt formal ET should be standard, 88% changed their practice as a result of the training, and 74% of those reporting strain noticed a decrease after their ET.

Conclusion:

Thus, at a high-volume robotics center, evidence-based ET was easily implemented, well-received, changed some surgeons'' practice, and decreased self-reported strain related to robotic surgery.     

Consensus and Different Perspectives on Treatment of Supracondylar Fractures of the Humerus in Children

Background

Although closed reduction and percutaneous pinning is accepted as the treatment of choice for displaced supracondylar fracture of the humerus, there are some debates on the pinning techniques, period of immobilization, elbow range of motion (ROM) exercise, and perceptions on the restoration of elbow ROM. This study was to investigate the consensus and different perspectives on the treatment of supracondylar fractures of the humerus in children.

Methods

A questionnaire was designed for this study, which included the choice of pinning technique, methods of elbow motion, and perception on the restoration of elbow ROM. Seventy-six orthopedic surgeons agreed to participate in the study and survey was performed by a direct interview manner in the annual meetings of Korean Pediatric Orthopedic Association and Korean Society for Surgery of the Hand. There were 17 pediatric orthopedic surgeons, 48 hand surgeons, and 11 general orthopedic surgeons.

Results

Ninety-six percent of the orthopedic surgeons agreed that closed reduction and percutaneous pinning was the treatment of choice for the displaced supracondylar fracture of the humerus in children. They showed significant difference in the choice of pin entry (lateral vs. crossed pinning, p = 0.017) between the three groups of orthopedic surgeons, but no significant difference was found in the number of pins, all favoring 2 pins over 3 pins. Most of the orthopedic surgeons used a removable splint during the ROM exercise period. Hand surgeons and general orthopedic surgeons tended to be more concerned about elbow stiffness after supracondylar fracture than pediatric orthopedic surgeons, and favored gentle passive ROM exercise as elbow motion. Pediatric orthopedic surgeons most frequently adopted active ROM exercise as the elbow motion method. Pediatric orthopedic surgeons and general orthopedic surgeons acknowledged that the patient''s age was the most contributing factor to the restoration of elbow motion, whereas hand surgeons acknowledged the amount of injury to be the most contributing factor.

Conclusions

More investigation and communication will be needed to reach a consensus in treating pediatric supracondylar fractures of the humerus between the different subspecialties of orthopedic surgeons, which can minimize malpractice and avoid medicolegal issues.     

Inadequate Glycemic Control Is Associated With Increased Surgical Site Infection in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background

The association between inadequate glycemic control and surgical site infection (SSI) following total joint arthroplasty (TJA) remains unclear. The aim of this study is to assess the relationship between perioperative glycemic control and the risk for SSI, mainly periprosthetic joint infection.

Particular Features of Surgical Site Infection in Posterior Lumbar Interbody Fusion

Background

Previous reports have observed differences only in infection rates between posterolateral fusion and posterior lumbar interbody fusion (PLIF). There have been no reports that describe the particular features of surgical site infection (SSI) in PLIF. In this study, we endeavor to identify the distinguishing characteristics and risk factors of SSI in PLIF.

Methods

Our study undertook a review of a case series of an institute. Patients who had undergone PLIF consecutively in the author''s hospital were reviewed. Two proactive procedures were introduced during the study period. One was irrigation of the autolocal bone, and the other was the intradiscal space irrigation with a nozzle. Infection rate and risk factors were analyzed. For subgroup analysis, the elapsed time to a diagnosis (ETD), clinical manifestations, hematologic findings, and causative bacteria were examined in patients with SSI.

Results

In a total of 1,831 cases, there were 30 cases of SSI (1.6%). Long operation time was an independent risk factor (p = 0.008), and local bone irrigation was an independent protective factor (p = 0.001). Two cases of referred SSI were included in the subgroup analysis. There were 6/32 (19%) superficial incisional infections (SII), 6/32 (19%) deep incisional infections (DII), and 20/32 (62%) organ/space infections (O/SI). The difference of incidence among three groups was significant (p = 0.002).The most common bacteria encountered were methicillin-resistant Staphylococcus epidermidis followed by methicillin-resistant S. aureus in incisional infections, and no growth followed by S. epidermidis in O/SI. ETD was 8.5 ± 2.3 days in SII, 8.7 ± 2.3 days in DII and 164.5 ± 131.1 days in O/SI (p = 0.013).

Conclusions

The rate of SSI in PLIF was 1.6%, with the most common type being O/SI. The causative bacteria of O/SI was of lower virulence than in the incisional infection, and thus diagnosis was delayed due to its latent and insidious feature. Contamination of auto-local bone was presumed attributable to the progression of SSI. Irrigation of auto-local bone helped in the reduction of SSI.     

Infection Prevention and Evaluation of Fever After Laparoscopic Hysterectomy

Background:

Surgical site infection (SSI) is a common complication of hysterectomy. Minimally invasive hysterectomy has lower infection rates than abdominal hysterectomy. The lower SSI rates reflect the role and benefit in infection control of having minimal incisions, rather than a large anterior abdominal wall incision. Despite the lower rates, SSI after laparoscopic hysterectomy is not uncommon. In this article, we review pre-, intra-, and postoperative risk factors for infection. Rates of postoperative fever after laparoscopic hysterectomy and when evaluation for infection is warranted in a febrile patient are also reviewed.

Database:

PubMed was searched for English-only articles using National Library of Medicine Medical Subject Headings (MESH) terms and keywords including but not limited to “postoperative,” “surgical site,” “infection,” “fever,” “laparoscopic,” “laparoscopy,” and “hysterectomy.”

Conclusions:

Reducing hospital-acquired infections such as SSI is one of the more effective ways of improving patient safety. Knowledge and understanding of risk factors for infection following laparoscopic hysterectomy enable the gynecologic surgeon or hospital to implement targeted preventive measures.     

Decreased Hospital Costs and Surgical Site Infection Incidence With a Universal Decolonization Protocol in Primary Total Joint Arthroplasty

Background

Staphylococcus aureus colonization has been identified as a key modifiable risk factor in the reduction of surgical site infections (SSI) related to elective total joint arthroplasty (TJA). We investigated the incidence of SSIs and cost-effectiveness of a universal decolonization protocol without screening consisting of nasal mupirocin and chlorhexidine before elective TJA compared to a program in which all subjects were screened for S aureus and selectively treated if positive.

Survey of terminology used for the intraoperative direction of C-arm fluoroscopy

Background

Orthopedic surgeons depend on the intraoperative use of fluoroscopy to facilitate procedures across all subspecialties. The versatility of the C-arm fluoroscope allows acquisition of nearly any radiographic view. This versatility, however, creates the opportunity for difficulty in communication between surgeon and radiation technologist. Poor communication leads to delays, frustration and increased exposure to ionizing radiation. There is currently no standard terminology employed by surgeons and technologists with regards to direction of the fluoroscope.

Methods

The investigation consisted of a web-based survey in 2 parts. Part 1 was administered to the membership of the Canadian Orthopedic Association, part 2 to the membership of the Canadian Association of Medical Radiation Technologists. The survey consisted of open-ended or multiple-choice questions examining experience with the C-arm fluoroscope and the terminology preferred by both orthopedic surgeons and radiation technologists.

Results

The survey revealed tremendous inconsistency in language used by orthopedic surgeons and radiation technologists. It also revealed that many radiation technologists were inexperienced in operating the fluoroscope.

Conclusion

Adoption of a common language has been demonstrated to increase efficiency in performing defined tasks with the fluoroscope. We offer a potential system to facilitate communication based on current terminology used among Canadian orthopedic surgeons and radiation technologists.     

Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up

Introduction

Elective laparoscopic cholecystectomy (LC) is performed routinely as day-case surgery. Most hospital trusts have a policy of no routine postoperative outpatient follow-up although there are no formal guidelines on this. The aim of this retrospective study was to identify the incidence of complications, the degree of symptom resolution and patient satisfaction with a view to formally appraising the need for outpatient follow-up.

Methods

Patients who underwent LC in the period between February 2011 and June 2012 were contacted retrospectively by telephone. A standardised questionnaire was used to ascertain the incidence of surgical site infection (SSI), other complications, symptom resolution and patient satisfaction.

Results

A total of 211 responses were collected. The rate of SSI was 7.6% (n=16), with the only specific risk factor being smoking (p=0.027). All other complications had a combined incidence of 7% (n=15). There was complete resolution of symptoms in 64% of patients. Of the 36% of patients with residual symptoms, 45% described abdominal discomfort or pain, 41% described reflux symptoms and 14% complained of diarrhoea. Patient satisfaction was very high (96%), yet 33% of patients visited their general practitioner postoperatively in relation to their surgery.

Conclusions

Patients are highly satisfied with elective day-case LC. However, SSI is not uncommon, occurring in 1 in 13 patients. Although the majority of patients experience complete symptom resolution, a significant proportion do not. In our experience, routine outpatient follow-up is not required. Nevertheless, the lack of formal follow-up may prove a missed learning opportunity, potentially resulting in inappropriate patient selection for surgery.     

Treatment preferences for trigger digit by members of the American Association for Hand Surgery

Background

Trigger digit is a common pathology encountered by hand surgeons, but there is a lack of evidence-based guidelines. We investigated the treatment preferences of hand surgeons and explored whether geographic location, type of residency training, or clinical experience is associated with differences in practice.

Methods

An online survey was distributed via email by the American Association for Hand Surgery to 615 members. The survey consisted of 17 questions related to conservative and operative management of trigger digits.

Results

One hundred thirty-nine unique responses were received (22.6 %). Geographic distribution of respondents encompassed the entire USA and was not associated with variations in practice. Of the respondents, 56.8 % were trained in orthopedic surgery while 37.4 % had plastic surgery training. In regards to duration of practice, 8.6 % were in practice for up to 5 years, 29.5 % for 6–15 years, 33.8 % for 16–25 years, and 28.1 % for more than 25 years. Notably, the great majority of respondents preferred corticosteroid injections for initial treatment. Those who were willing to give three or more injections prior to surgery were more likely to be plastic surgeons in practice for 16 years or more. A large minority of surgeons utilized splinting in their conservative management. Orthopedic surgeons were more likely to perform tenolysis during pulley release and more likely to use monitored anesthesia care.

Conclusions

Variation exists between the treatment algorithms of hand surgeons when managing a trigger digit. Some of these differences may be attributable to the type of training or the duration of clinical practice.     

Antibiotic prophylaxis for total joint replacement surgery: results of a survey of Canadian orthopedic surgeons

Background

The role of perioperative antibiotic prophylaxis in total joint replacement (TJR) surgery is well established. Whereas guidelines have been published in some countries, in Canada controversy persists concerning the best clinical practice for perioperative antibiotic prophylaxis in TJR.

Methods

We conducted a survey of 590 practising orthopedic surgeons performing TJR in Canada to assess current antibiotic prophylaxis practice. The survey included questions pertaining to antibiotic prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision arthroplasty setting, as well as postoperative wound drainage evaluation and management.

Results

The response rate after 2 mail-outs was 410 of 590 (69.5%). Current antibiotic prophylaxis regimens varied widely among surgeons, underscoring the controversy that exists regarding what constitutes best clinical practice.

Conclusion

Opinions regarding use of perioperative antibiotic prophylaxis in TJR vary widely among orthopedic surgeons in Canada, illustrating the controversy as to what constitutes best clinical practice. This survey also points to a lack of consensus about the current management of postoperative wound drainage.     

Chronic stress and coping among cardiac surgeons: a single center study

Introduction

Cardiac surgeons stress may impair their quality of life and professional practice.

Objective

To assess perceived chronic stress and coping strategies among cardiac surgeons.

Methods

Twenty-two cardiac surgeons answered two self-assessment questionnaires, the Trier Inventory for Chronic Stress and the German SGV for coping strategies.

Results

Participants mean age was 40±14.1 years and 13 were male; eight were senior physicians and 14 were residents. Mean values for the Trier Inventory for Chronic Stress were within the normal range. Unexperienced physicians had significantly higher levels of dissatisfaction at work, lack of social recognition, and isolation (P<0.05). Coping strategies such as play down, distraction from situation, and substitutional satisfaction were also significantly more frequent among unexperienced surgeons. "Negative" stress-coping strategies occur more often in experienced than in younger colleagues (P=0.029). Female surgeons felt more exposed to overwork (P=0.04) and social stress (P=0.03).

Conclusion

Cardiac surgeons show a tendency to high perception of chronic stress phenomena and vulnerability for negative coping strategies.     

Laminar flow reduces cases of surgical site infections in vascular patients

Introduction

Numerous strategies are employed routinely in an effort to lower rates of surgical site infections (SSIs). A laminar flow theatre environment is generally used during orthopaedic surgery to reduce rates of SSIs. Its role in vascular surgery, especially when arterial bypass grafts are used, is unknown.

Methods

A retrospective review of a prospectively maintained database was undertaken for all vascular procedures performed by a single consultant over a one-year period. Cases were performed, via random allocation, in either a laminar or non-laminar flow theatre environment. Demographic data, operative data and evidence of postoperative SSIs were noted. A separate subgroup analysis was undertaken for patients requiring an arterial bypass graft. Univariate and multivariate logistical regression was undertaken to identify significant factors associated with SSIs.

Results

Overall, 170 procedures were analysed. Presence of a groin incision, insertion of an arterial graft and a non-laminar flow theatre were shown to be predictive of SSIs in this cohort. In the subgroup receiving arterial grafts, only a non-laminar flow theatre environment was shown to be predictive of an SSI.

Conclusions

This study suggests that laminar flow may reduce incidences of SSI, especially in the subgroup of patients receiving arterial grafts.     

Evidence-based surgery--evidence from survey and citation analysis in orthopaedic surgery

INTRODUCTION

The results of a survey on evidence-based surgery (EBS) among members of the American Academy of Orthopedic Surgeons (AAOS) and the British Orthopaedic Association (BOA) are presented. The study also analyzes the citations earned by articles with different levels of evidence (LOE) to see if LOE have any bearing on the importance attached to the articles by authors and contributors to the journals.

SUBJECTS AND METHODS

The questionnaire was e-mailed to 1000 randomly chosen consultant orthopaedic surgeons who were members of either the AAOS or the BOA. Participants were provided with the option of responding through web-based entry. For citation analysis, citation data were gathered from the Journal of Bone and Joint Surgery (American volume) between the years 2003 and 2007 (5-year period).

RESULTS

The survey showed that awareness and access to EBS have improved greatly over the years. At the present time, these factors are not important barriers to the implementation of EBS in clinical practice in developed countries. There was a statistically significant difference in those with and without additional qualifications with regard to the approach to EBS. However, an equal percentage of surgeons with and without additional qualifications felt that it was difficult to adhere to EBS guidelines in daily clinical practice. Citation analysis showed that readers of professional journals attach importance to LOE category of the article and tend to cite level-I evidence articles more than other articles.     

Buddy Taping: Is It a Safe Method for Treatment of Finger and Toe Injuries?

Background

Buddy taping is a well known and useful method for treating sprains, dislocations, and other injuries of the fingers or toes. However, the authors have often seen complications associated with buddy taping such as necrosis of the skin, infections, loss of fixation, and limited joint motion. To our knowledge, there are no studies regarding the complications of buddy taping. The purpose of this study was to report the current consensus on treating finger and toe injuries and complications of buddy taping by using a specifically designed questionnaire.

Methods

A questionnaire was designed for this study, which was regarding whether the subjects were prescribed buddy taping to treat finger and toe injuries, reasons for not using it, in what step of injury treatment it was use, indications, complications, kinds of tape for fixation, and special methods for preventing skin injury. Fifty-five surgeons agreed to participate in the study and the survey was performed in a direct interview manner at the annual meetings of the Korean Pediatric Orthopedic Association and Korean Society for Surgery of the Hand, in 2012.

Results

Forty-eight surgeons (87%) used buddy taping to treat finger and toe injuries, especially proximal interphalangeal (PIP) injuries of the hand, finger fractures, toe fractures, metacarpophalangeal injuries of the hand, and PIP injuries of the foot. Sixty-five percent of the surgeons experienced low compliance. Forty-five percent of the surgeons observed skin injuries on the adhesive area of the tape, and skin injuries between the injured finger and healthy finger were observed by 45% of the surgeons.

Conclusions

This study sheds light on the current consensus and complications of buddy taping among physicians. Low compliance and skin injury should be considered when the clinician treats finger and toe injuries by using buddy taping.