Evaluation of the SENIC risk index in a Spanish university hospital.

OBJECTIVE: To assess the performance of the Study of the Efficacy of Nosocomial Infection Control (SENIC) risk index for the evaluation of the risk of surgical-site infection (SSI) in a country other than the United States, having a different health system. SETTING: 350-bed university hospital in Spain belonging to the National Health System (Insalud). DESIGN: Observational cohort study of 1,019 patients who underwent consecutive surgery from January to December 1992. Surgical-infection risk factors assessed by the traditional wound-classification system (clean, clean-contaminated, contaminated, and dirty-infected wound) and by the SENIC risk index (length of intervention more than 2 hours, more than three discharge diagnoses, abdominal surgery, and contaminated or dirty-infected wound) were compared by forward logistic regression. RESULTS: The SENIC risk index showed a greater ability to predict SSI than the traditional wound-classification system. The study carried out in our institution reproduced the estimators provided by the SENIC study in the United States. The SENIC risk index provided a stepwise increase in SSI rates, according to the number of factors present, for every traditional wound-classification group. In the case of clean wounds, the incidence of surgical infection (per 100 interventions) increased (1.5, 2.4, 5.3, and 50; P<.001) for patients having from zero to three risk factors of the SENIC risk index. CONCLUSIONS: This study shows that the SENIC risk index results are reproducible, and the index can be used to compare rates of wound infection across countries with different health systems than the United States.     

Incidence of and risk factors for surgical-site infections in a Peruvian hospital.

OBJECTIVE: To determine the incidence of and risk factors for surgical-site infections (SSIs) after abdominal surgery. DESIGN: A cohort study was conducted from January to June 1998. CDC criteria for SSI and the NNIS System risk index were used. SETTING: A tertiary-care hospital in Peru. PATIENTS: Adult patients undergoing abdominal surgery who consented were enrolled and observed until 30 days after surgery. Patients who had undergone surgery at another hospital or who died or were transferred to another hospital within 24 hours after surgery were excluded. RESULTS: Four hundred sixty-eight patients were enrolled. Their mean age was 37.2 years. One hundred twenty-five patients developed SSIs, 18% of which were identified after discharge. The overall incidence rate (IR) was 26.7%. The IR was 13.9% for clean, 15.9% for clean-contaminated, 13.5% for contaminated, and 47.2% for dirty interventions. The IR was 3.6% for NNIS System risk index 0 and 60% for index 3. Risk factors for SSI on logistic regression analysis were dirty or infected wound (RR, 3.8; CI95, 1.7-8.4), drain use longer than 9 days (RR, 6.0; CI95, 2.5-12.5), and length of surgery greater than the 75th percentile (RR, 2.1; CI95, 1.0-4.4). Patients with SSI had a longer hospital stay than did non-infected patients (14.0 vs 6.1 days; p < .001). CONCLUSIONS: SSI is a major problem in this hospital, which has a higher IR (especially for clean interventions) than those of developed countries. In developing countries, prevention of SSI should include active surveillance and interventions targeting modifiable risk factors.     

Incidence of vancomycin-resistant Enterococcus at a university hospital in Brazil

OBJECTIVE: Vancomycin-resistant Enterococcus (VRE) is today one of the principal microorganisms implicated in nosocomial infections. Thus, a study was carried out with the objective of evaluating its epidemiology at a tertiary-level teaching hospital. METHODS: This was a three-year retrospective epidemiological study conducted from 2000 to 2002. Samples of VRE-positive clinical cultures at a 660-bed university hospital were analyzed. The incidence of VRE and the main anatomical sites and hospital units from which it was isolated were defined. Differences between the variables over the three years of the study were verified, and these were considered significant when p<0.05. RESULTS: There was a progressive increase in the vancomycin resistance in the clinical cultures that were positive for Enterococcus spp., over the three years of the study. In 2000, 9.5% of the samples were vancomycin-resistant, and this increased to 14.7% in 2001 and 15.8% in 2002. The hospital units with the largest numbers of isolates were, respectively, the emergency ward (19.5%) and the general intensive care unit (15%). The anatomical sites with the highest amounts of isolates included: urine (36%) and blood (20%). CONCLUSIONS: With the progressive increase in the incidence of vancomycin resistance and the VRE rate, it is concluded that more effective control measures are needed for deterring the dissemination of VRE.     

Surgical site infection in patients submitted to orthopedic surgery: the NNIS risk index and risk prediction

The applicability of the risk index for surgical site infection of the National Nosocomial Infection Surveillance (NNIS) has been evaluated for its performance in different surgeries. In some procedures, it is necessary to include other variables to predict. Objective: to evaluate the applicability of the NNIS index for prediction of surgical site infection in orthopedic surgeries and to propose an alternative index. The study involved a historical cohort of 8236 patients who had been submitted to orthopaedic surgery. Statistical analysis was performed using multivariate logistic regression to fit the model. The incidence of infection was 1.41%. Prediction models were evaluated and compared to the NNIS index. The proposed model was not considered a good predictor of infection, despite moderately stratified orthopedic surgical patients in at least three of the four scores. The alternative model scored higher than the NNIS models in the prediction of infection.     

Finding a method for optimizing risk adjustment when comparing surgical-site infection rates.

OBJECTIVE: To investigate whether stratification of the risk of developing a surgical-site infection (SSI) is improved when a logistic regression model is used to weight the risk factors for each procedure category individually instead of the modified NNIS System risk index. DESIGN AND SETTING: The German Nosocomial Infection Surveillance System, based on NNIS System methodology, has 273 acute care surgical departments participating voluntarily. Data on 9 procedure categories were included (214,271 operations). METHODS: For each of the procedure categories, the significant risk factors from the available data (NNIS System risk index variables of ASA score, wound class, duration of operation, and endoscope use, as well as gender and age) were identified by multiple logistic regression analyses with stepwise variable selection. The area under the receiver operating characteristic (ROC) curve resulting from these analyses was used to evaluate the predictive power of logistic regression models. RESULTS: For most procedures, at least two of the three variables contributing to the NNIS System risk index were shown to be independent risk factors (appendectomy, knee arthroscopy, cholecystectomy, colon surgery, herniorrhaphy, hip prosthesis, knee prosthesis, and vascular surgery). The predictive power of logistic regression models (including age and gender, when appropriate) was low (between 0.55 and 0.71) and for most procedures only slightly better than that of the NNIS System risk index. CONCLUSION: Without the inclusion of additional procedure-specific variables, logistic regression models do not improve the comparison of SSI rates from various hospitals.     

Bone wax as a risk factor for surgical-site infection following neurospinal surgery.

Surgical-site infection occurred in 6 of 42 neurospinal cases in which bone wax was used and in 1 of 72 cases in which it was not used during a 3-month period (P < .01). Increased risk of infection should be considered when using bone wax as a hemostatic agent.     

Postoperative wound infection at a university hospital in Jeddah, Saudi Arabia.

A prospective study was made of 1418 surgical wounds at the 250-bed King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Daily examinations of wounds, cultures of all suspicious wounds and 28 days outpatient clinic follow-up were performed. The overall infection rate was 9%. The infection rate after clean surgery was 9.5%. High rates of infections were noted after colon resection (19%), caesarean section (19%), abdominal hysterectomy (10%) and cholecystectomy (10%). The infection rates after appendectomy, mastectomy and herniorrhaphy were approximately 7%. A lower rate of infection was seen after thyroidectomy (2%). The incidence of infection was significantly related to pre-operative stay in hospital and to duration of operation.     

A new surgical-site infection risk index using risk factors identified by multivariate analysis for patients undergoing coronary artery bypass graft surgery.

OBJECTIVES: To develop a new, simple, and practical risk index for patients undergoing coronary artery bypass graft (CABG) surgery, to develop a preoperative risk index that is predictive of surgical-site infection (SSI), and to compare the new risk indices with the National Nosocomial Infections Surveillance (NNIS) System risk index. DESIGN: Potential risk factor and infection data were collected prospectively and analyzed by multivariate analysis. Two new risk indices were constructed and then compared with the NNIS System risk index for predictive power for SSI. SETTING: Alfred Hospital is a 350-bed, university-affiliated, tertiary-care referral center. The cardiothoracic unit performs approximately 650 CABG procedures per year. PATIENTS: All patients undergoing CABG surgery within the cardiothoracic unit at Alfred Hospital between December 1, 1996, and September 29, 2000, were included. RESULTS: Potential risk factor data were complete for 2,345 patients. There were 199 SSIs. Obesity (odds ratio [OR], 1.78; 95% confidence interval [CI95], 1.24 to 2.55), peripheral or cerebrovascular disease (OR, 1.64; CI95, 1.16 to 2.33), insulin-dependent diabetes mellitus (OR, 2.29; CI95, 1.15 to 4.54), and a procedure lasting longer than 5 hours (OR, 1.75; CI95, 1.18 to 2.58) were identified as independent risk factors for SSI. With the use of a different combination of these risk factors, two risk indices were constructed and compared using the Goodman-Kruskal nonparametric correlation coefficient (G). kisk index B had the highest G value (0.3405; CI95, 0.2245 to 0.4565), compared with the NNIS System risk index G value (0.3142; CI95, 0.1462 to 0.4822). The G value for risk index A, constructed from preoperative variables only, was 0.3299 (CI9,, 0.2039 to 0.4559). CONCLUSION: Two new risk indices have been developed. Both indices are as predictive as the NNIS System risk index. One of the new risk indices can also be applied preoperatively.     

NNIS风险指数在手术部位感染应用的效果评估

目的评估NNIS风险指数在手术部位感染的应用效果,为NNIS风险调整作参考。方法回顾性收集2014年1月-2016年8月12所医院14 308例手术病例资料,计算不同手术不同NNIS风险组的感染率,应用Spearman秩相关检验分析NNIS风险等级与感染率的相关关系,以受试者工作特征曲线(ROC)下面积(AUC)评价NNIS风险指数对不同手术术后感染的预测能力。结果 NNIS-0、1级、2级、3级感染率分别为1.77%、5.85%、13.13%、26.14%,Spearman秩相关系数为0.642,P<0.01;结直肠切除、开腹胆囊及胆管手术的AUC分别为0.731、0.721、0.717,长骨骨折切开复位内固定、髋关节置换、冠状动脉搭桥、腹式子宫切除的AUC分别为0.634、0.608、0.646、0.623,剖宫产AUC为0.502。结论 NNIS风险指数作为手术部位感染风险分层工具判别能力较好,对感染率高的手术预测能力优于感染率低的手术,如能根据我国的情况对NNIS风险指数进行风险调整或许能够让其作用发挥更有效。     

Applicability of two surgical-site infection risk indices to risk of sepsis in surgical patients.

OBJECTIVE: To compare the ability of the Study of the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infection Surveillance (NNIS) indices to predict the development of nosocomial sepsis in subjects undergoing surgery. DESIGN: 1-year prospective case-control study. SETTING: A tertiary-care center in Spain. PATIENTS: Cases were surgical patients with nosocomial sepsis defined using the criteria of the Consensus Conference on Sepsis, identified by daily prospective surveillance. METHODS: Controls were randomly selected from the daily list of surgical inpatients. Data were prospectively collected. To determine whether either index added explanatory information to the other, two methods were used. The first method involved computing a set of residuals for both variables. Residuals and primary variables were introduced in logistic regression models. The second method evaluated both indices with the Goodman-Kruskal (G) nonparametric coefficient. RESULTS: 99 cases and 97 controls were included. After controlling for confounders, both the SENIC index (P<.001) and the NNIS index (P=.04) showed a significant trend. Residuals of the SENIC index added discriminating ability to the NNIS index, whereas residuals of the NNIS index did not improve the prediction ability of the SENIC index. Similar results were yielded by the G statistic: the SENIC index showed higher predictive power than the NNIS index (G=0.56 vs G=0.41). CONCLUSIONS: Both indices performed about equally well for discriminating risk of nosocomial sepsis. The SENIC index had a somewhat better ability than the NNIS index only when the number of discharge diagnoses (not truly a predictive factor) were involved in the calculation of the SENIC index.     

Epidemiology of hospital-acquired urinary tract-related bloodstream infection at a university hospital

Little is known about the epidemiology of nosocomial urinary tract-related bloodstream infection. In a case series from an academic medical center, Enterococcus (28.7%) and Candida (19.6%) species were the predominant microorganisms, which suggests a potential shift from gram-negative microorganisms. A case-fatality rate of 32.8% highlights the severity of this condition.     

Occurrence of hospital infection among interned elderly in a university hospital

OBJECTIVE: Hospital infection is an important cause of morbidity and mortality in the elderly population. The objective of this study was to evaluate the occurrence of hospital infection and risk factors associated with it. METHODS: This is a prospective study of a sample of 332 elderly people, 60 years and older, interned in a university hospital, between September 1999 and February 2000. Sample size was calculated according to the Fisher and Belle formula, with a confidence interval of 0.95%, from a total of 760 elderly patients interned, in proportion to the number of patients present in each in-patient unit, in the 1997. Criteria for defining hospital infection were those established by the Center for Diseases and Prevention Control. Odds ratio and logistic regression were utilized for statistical analysis of the data. RESULTS: The rate of hospital infection was 23.6%. The prevalent topographies of infection were respiratory infections (27.6%), urinary tract infections (26.4%) and surgical wound infections (23.6%). The period of hospitalization of patients who did have hospital infections was 6.9 days, while those who had hospital infections were hospitalized for 15.9 days (p<0.05). Mortality rate among hospitalized patients was 9.6% and the rate of lethality among patients with hospital infection was 22.9% (p<0.05). Risk factors found for hospital infection were cholangiography (odds ratio (OR) =46.4, confidence interval 95% (CI95%) =4.4-485); diabetes mellitus (OR=9.9, CI 95% =4.4-22.3); chronic obstructive pulmonary disease (OR=8.3, CI 95% =2.9-23.7); urinary catheters (OR=5, CI 95% =2.7-11.8); hospitalization with community infection (OR=3.9, CI 95% =1.7-8.9) and mechanic ventilation (OR=3.8, CI 95% =1.9-6.3). CONCLUSIONS: Hospital infection presented elevated incidence and lethality and it increased the period of hospitalization among the elderly studied.     

Risk factors for spinal surgical-site infections in a community hospital: a case-control study.

OBJECTIVE: To characterize risk factors for surgical-site infection after spinal surgery. DESIGN: A case-control study. SETTING: A 113-bed community hospital. METHOD: From January 1998 through June 2000, the incidence of surgical-site infection in patients undergoing laminectomy, spinal fusion surgery, or both increased at community hospital A. We compared 13 patients who acquired surgical-site infections after laminectomy, spinal fusion surgery, or both with 47 patients who were operated on during the same time period but did not acquire a surgical-site infection. Information collected included demographics, risk factors, personnel involved in the operations, length of hospital stay, and hospital costs. RESULTS: Of 13 case-patients, 9 (69%) were obese, 9 (69%) had spinal compression, 5 (38.5%) had a history of tobacco use, and 4 (31%) had diabetes. Oxacillin-sensitive Staphylococcus aureus (6 of 13; 46%) was the most common organism isolated. Significant risk factors for postoperative spinal surgical-site infection were dural tear during the surgical procedure and the use of glue to cement the dural patch (3 of 13 [23%] vs 1 of 47 [2.1%]; P = .02) and American Society of Anesthesiologists risk class of 3 or more (6 of 13 [46.2%] vs 7 of 47 [15%]; P = .02). Case-patients were more likely to have prolonged length of stay (median, 16 vs 4 days; P< .001). The average excess length of stay was 11 days and the excess cost per case was $12,477. CONCLUSION: Dural tear and the use of glue should be evaluated as potential risk factors for spinal surgical-site infection. Systematic observation for potential lapses in sterile technique and surgical processes that may increase the risk of infection may help prevent spinal surgical-site infection.     

Evaluation of a university hospital unit specialising in treating adults at risk of suicide

In France, suicide prevention has been a public health priority since 1992. Half of all suicide attempts are repeated attempts made by people who have already tried to commit suicide, and the risk of death increases by 1% after the first attempt. Today, hospitalisation has become an unavoidable consequence for those who have attempted suicide, and recommendations for best practice were recently issued in France (1998). The objective of this study was two-fold: 1) to assess the quality of management and care provided for patients hospitalised in a university hospital in Angers after having attempted suicide, an evaluation that was based in part on the criteria of the National Agency on Health Accreditation and Evaluation (ANAES); and 2) the demonstrate the value and high utility of such a unit specialising in caring for patients recovering from attempted suicide. The unit has now been in existence for over 5 years, and has treated 42% of such patients who require hospitalisation. One investigator was responsible for asking 251 patients (on the day of their release) who had been hospitalised anytime during the given 6 month period (November 2002 - May 2003) to complete a questionnaire containing approximately 100 items. In order to be eligible for the study, patients had to be older than 16 years and hospitalised for at least 48 hours. 155 questionnaires were completed (62%), and there were 96 patients were notable to participate on the day of their release. Nine of the 14 criteria recommended by the ANAES were met in over 65% of the cases, and three in less than 40%. Following the analysis of the data through logic regression, it remained clear that unit specialising in the care of people who have attempted suicide was better able and equipped to meet the standards of the ANAES' recommendations than a standard hospital medical unit. Visits with a psychiatrist or psychiatric nurse occurred more frequently in the specialised unit (p < 0.04), interviews with the patients' family members were more frequent (p < 0.01), the confidentiality of the discussions from the interviews was more often respected and maintained (p < 0001), and the information provided by the caregivers and staff was more effective in the specialised unit (p < 0.03). One of the main benefits and results of these aforementioned differences is that the patients in the suicide unit more often perceived a distinct improvement in their depression (p < 0.007). All of these arguments indicate that hospitalisation in a special unit provides real benefits to patients, and the results of this study advocate strongly in favour of increasing the capacity of the unit, which is currently limited to only 6 beds.     

Compliance with isolation precautions at a university hospital.

Compliance with isolation precautions recommended by the Centers for Disease Control and Prevention (CDC) was evaluated in 3 hospital-wide observational surveys. The compliance rate, by type of isolation, was as follows: droplet transmission, 100% (4 observations); airborne transmission, 61.5% (13 observations); contact isolation, 73.3% (165 observations); and protective isolation, 73.6% (72 observations). As with hand hygiene, there is suboptimal compliance with recommended isolation precautions.     

The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost.

OBJECTIVE: To measure the impact of orthopedic surgical-site infections (SSIs) on quality of life, length of hospitalization, and cost. DESIGN: A pairwise-matched (1:1) case-control study within a cohort. SETTING: A tertiary-care university medical center and a community hospital. PATIENTS: Cases of orthopedic SSIs were prospectively identified by infection control professionals. Matched controls were selected from the entire cohort of patients undergoing orthopedic surgery who did not have an SSI. Matching variables included type of surgical procedure, National Nosocomial Infections Surveillance risk index, age, date of surgery, and surgeon. MAIN OUTCOME MEASURES: Quality of life, duration of postoperative hospital stay, frequency of hospital readmission, overall direct medical costs, and mortality rate. RESULTS: Fifty-nine SSIs were identified. Each orthopedic SSI accounted for a median of 1 extra day of stay during the initial hospitalization (P = .001) and a median of 14 extra days of hospitalization during the follow-up period (P = .0001). Patients with SSI required more rehospitalizations (median, 2 vs 1; P = .0001) and more total surgical procedures (median, 2 vs 1; P = .0001). The median total direct cost of hospitalizations per infected patient was $24,344, compared with $6,636 per uninfected patient (P = .0001). Mortality rates were similar for cases and controls. Quality of life was adversely affected for patients with SSI. The largest decrements in scores on the Medical Outcome Study Short Form 36 questionnaire were seen in the physical functioning and role-physical domains. CONCLUSIONS: Orthopedic SSIs prolong total hospital stays by a median of 2 weeks per patient, approximately double rehospitalization rates, and increase healthcare costs by more than 300%. Moreover, patients with orthopedic SSIs have substantially greater physical limitations and significant reductions in their health-related quality of life.     

Prevalence of hospital infection and antibiotic use at a university medical center in Hong Kong

Hospital infection prevalence surveys were performed in our 1400-bed University medical centre in Hong Kong from 1985 to 1988. We investigated the rates of four major hospital-acquired infections (HAIs) (pneumonia, symptomatic urinary tract infection, surgical site infection and laboratory-confirmed bloodstream infection) in order to identify current distribution and any changes after 15 years. A one-day point prevalence study was performed on 7 September 2005. All inpatients were surveyed for HAIs, community-acquired infections (CAIs), risk factors, pathogenic isolates and antibiotics prescribed. Infections were diagnosed according to Centers for Disease Control and Prevention (CDC) criteria. In total, 1021 patients were surveyed; of these, 41 had 42 HAIs (4% prevalence) and 389 (38%) were receiving antibiotics. The commonest HAI was pneumonia (1.4%) followed by bloodstream infection (0.9%) and symptomatic urinary tract infection (0.8%). The prevalence of postoperative surgical site infection was 5.6%. The nosocomial prevalence rate was highest in the Intensive Care Unit, followed by the Pediatric and Neonatal Intensive Care Units, Children's Cancer Centre/Bone Marrow Transplant Unit and Orthopaedics with Traumatology. Meticillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa were the commonest pathogens. The rates are significantly lower than previously and reflect the increased resources for infection control made available following the outbreak of severe acute respiratory syndrome (SARS).     

Student utilization of health services at a university hospital in Turkey.

This paper gives the results of the first pilot study of health care utilization by Turkish university students who receive much of their student health-related services from an affiliated university hospital. The survey was distributed to 393 students and a response rate of 59.8% was obtained. In general students did not report satisfaction with the health services they received. This finding is significant because the hospital concerned is considered 'state of the art' in Turkey. Significant levels of dissatisfaction were noted across several treatment and provider variables, and comparisons with American health services are made. Suggestions for improving the student health services in the country are generated and future research recommendations are highlighted.