Rachel R. Kelz

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017

Importance The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. Objective To provide new and updated evidence-based recommendations for the prevention of SSI. Evidence Review A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. Findings Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. Conclusions and Relevance This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Validation of new readmission data in the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND Hospital readmissions are gathering increasing attention as a measure of health care quality and as a cost-saving target. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) recently began collecting data related to 30-day postoperative readmissions. Our objectives were to assess the accuracy of the ACS NSQIP readmission variable by comparison with the medical record, and to evaluate the readmission variable against administrative data. STUDY DESIGN Readmission data captured in ACS NSQIP at a single academic institution between January and December 2011 were compared with data abstracted from the medical record and administrative data. RESULTS Of 1,748 cases captured in ACS NSQIP, 119 (6.8%) had an all-cause readmission event identified, and ACS NSQIP had very high agreement with chart review for identifying all-cause readmission events (κ = 0.98). For 1,110 inpatient cases successfully matched with administrative data, agreement with chart review for identifying all-cause readmissions was also very high (κ = 0.97). For identifying unplanned readmission events, ACS NSQIP had good agreement with chart review (κ = 0.67). Overall, agreement with chart review on cause of readmission was higher for ACS NSQIP (κ = 0.75) than for administrative data (κ = 0.46). CONCLUSIONS The ACS NSQIP accurately captured all-cause and unplanned readmission events and had good agreement with the medical record with respect to cause of readmission. Administrative data accurately captured all-cause readmissions, but could not identify unplanned readmissions and less consistently agreed with chart review on cause. The granularity of clinically collected data offers tremendous advantages for directing future quality efforts targeting surgical readmission.

Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data.

Objective:To examine the association between surgical start time and morbidity and mortality for nonemergent procedures. Summary Background Data:Patients require medical services 24 hours a day. Several studies have demonstrated a difference in outcomes over the course of the day for anesthetic adverse events, death in the ICU, and dialysis care. The relationship between operation start time and patient outcomes is yet undefined. Methods:We performed a retrospective cohort study of 144,740 nonemergent general and vascular surgical procedures performed within the VA Medical System 2000–2004 and entered into the National Surgical Quality Improvement Program Database. Operation start time was the independent variable of interest. Logistic regression was used to adjust for patient and procedural characteristics and to determine the association between start time and, in 2 independent models, mortality and morbidity. Results:Unadjusted later start time was significantly associated with higher surgical morbidity and mortality. After adjustment for patient and procedure characteristics, mortality was not significantly associated with start time. However, after appropriate adjustment, operations starting between 4 pm and 6 pm were associated with an elevated risk of morbidity (OR = 1.25, P ≤ 0.005) over those starting between 7 am and 4 pm as were operations starting between 6 pm and 11 pm (OR = 1.60, P ≤ 0.005). Conclusions:When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine “business” hours within the VA System may face an elevated risk of complications that warrants further evaluation.

Changes in Prognosis After the First Postoperative Complication

Background:Postoperative complications are common in the Medicare population, yet no study has formally quantified the change in prognosis that occurs after a broad range of first complications. Objective:We sought to estimate the relative severity of 24 first postoperative complications. Research Design:We undertook a multivariate matched, population-based, case-control study of death after surgery in a sample of 1362 Pennsylvania Medicare patients. Subjects:Cases (681 deaths) were selected randomly using claims from 1995–1996. Models were developed to scan all Pennsylvania claims, looking for similar controls that did not die. Measures:Charts were abstracted, complications identified, and models were constructed to estimate the odds of dying after any 1 of 24 first postoperative complications. Results:The odds of dying within 60 days increased 3.4-fold (95% confidence interval [CI] 2.5–4.7) in patients with complications as compared with those without complications. A first complication of respiratory compromise was associated with a 7.2-fold increase in the odds of dying (95% CI 4.5–11.6). The first complications of pneumonia or congestive heart failure were associated with, respectively, 5-fold (95% CI 2.1–12.1) and 5.1-fold (2.3–11.1) increases in odds of dying as compared with no complication. Conclusions:First complications after surgery, even seemingly mild ones, may radically alter the patients risk of death. First complications often begin the cascade of complications that end in death. Caregivers should consider the first complication as a timely signal of a changed clinical situation demanding a reevaluation of the patients care. Researchers may use these estimates to determine the relative severity of a broad range of first or early complications.

Medical and financial risks associated with surgery in the elderly obese.

Objective: To study the medical and financial outcomes associated with surgery in elderly obese patients and to ask if obesity itself influences outcomes above and beyond the effects from comorbidities that are known to be associated with obesity. Background: Obesity is a surgical risk factor not present in Medicares risk adjustment or payment algorithms, as BMI is not collected in administrative claims. Methods: A total of 2045 severely or morbidly obese patients (BMI ≥ 35 kg/m2, aged between 65 and 80 years) selected from 15,914 elderly patients in 47 hospitals undergoing hip and knee surgery, colectomy, and thoracotomy were matched to 2 sets of 2045 nonobese patients (BMI = 20–30 kg/m2). A “limited match” controlled for age, sex, race, procedure, and hospital. A “complete match” also controlled for 30 additional factors such as diabetes and admission clinical data from chart abstraction. Results: Mean BMI in the obese patients was 40 kg/m2 compared with 26 kg/m2 in the nonobese. In the complete match, obese patients displayed increased odds of wound infection: OR (odds ratio) = 1.64 (95% CI: 1.21, 2.21); renal dysfunction: OR = 2.05 (1.39, 3.05); urinary tract infection: OR = 1.55 (1.24, 1.94); hypotension: OR = 1.38 (1.07, 1.80); respiratory events: OR = 1.44 (1.19, 1.75); 30-day readmission: OR = 1.38 (1.08, 1.77); and a 12% longer length of stay (8%, 17%). Provider costs were 10% (7%, 12%) greater in obese than in nonobese patients, whereas Medicare payments increased only 3% (2%, 5%). Findings were similar in the limited match. Conclusions: Obesity increases the risks and costs of surgery. Better approaches are needed to reduce these risks. Furthermore, to avoid incentives to underserve this population, Medicare should consider incorporating incremental costs of caring for obese patients into payment policy and include obesity in severity adjustment models.

National Cancer Institute designation predicts improved outcomes in colorectal cancer surgery.

Background:Although National Cancer Institute (NCI) designation as a cancer center is based almost solely on research activities, it is often viewed, by patients and referring providers, as an indication of clinical excellence. Objective:To compare the short- and long-term outcomes of colon and rectal cancer surgery performed at NCI-designated centers to the outcomes after resection at non–NCI-designated hospitals. Methods:We performed a retrospective cohort study of Survival, Epidemiology, and End Results (SEER)-Medicare database patients undergoing segmental colectomy (n = 33,969) or proctectomy (n = 8591) for cancer from 1996–2003. Multivariate logistic regression, with and without propensity scores, and matched conditional regression were performed to evaluate the relationship between NCI status and postoperative mortality (in-hospital or 30-day death). The log-rank test, Kaplan-Meier curves, and Cox regression compared survival between hospital types. Results:We evaluated 33,969 colectomy and 8591 proctectomy patients. Postoperative mortality after colectomy was 6.7% at non-NCI and 3.2% at NCI centers. Mortality after proctectomy was 5.0% and 1.9%, respectively. These differences were significant when adjusted for patient and hospital characteristics. For both colon and rectal cancer patients, long-term mortality was significantly improved after resection at NCI centers (HR 0.84, P < 0.001; HR 0.85, P = 0.02, respectively). Conclusion:NCI designation is associated with lower risk of postoperative death and improved long-term survival. Possible factors responsible for these benefits include surgeon training, multidisciplinary care, and adherence to treatment guidelines. Studies are underway to elucidate the factors leading to improved patient outcomes.

The rise in metastasectomy across cancer types over the past decade

Although studies of metastasectomy have been limited primarily to institutional experiences, reports of favorable long‐term outcomes have generated increasing interest. In the current study, the authors attempted to define the national practice patterns in metastasectomy for 4 common malignancies with varying responsiveness to systemic therapy.

Morbidity and mortality after total gastrectomy for gastric malignancy using the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND Frequent perioperative morbidity and mortality have been observed in randomized surgical studies for gastric cancer, but specific patient factors associated with morbidity and mortality after total gastrectomy have not been well characterized. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011) for all patients with a gastric neoplasm undergoing total gastrectomy. Univariate and multivariate logistic regression analyses were performed to identify factors associated with an increased risk of morbidity or mortality. RESULTS In 1,165 patients undergoing total gastrectomy, 416 patients (36%) experienced a complication, and 55 died (4.7%) within 30 days of operation. In a reduced multivariate model, age >70 years, preoperative weight loss, splenectomy, and pancreatectomy were associated with morbidity, whereas age >70 years, weight loss, albumin <3 g/dL, and pancreatectomy were associated with mortality (P < .05 each). The number of present preoperative risk factors stratified morbidity from 26 to 46%, with an adjacent organ resection (splenectomy, pancreatectomy) associated with 56% morbidity. Similarly, mortality rates ranged from 0.4% in those without risk factors to 5 of 9 patients with all three preoperative factors present. Patients undergoing pancreatectomy had a 13% mortality rate. CONCLUSION Total gastrectomy for malignancy is associated with substantial morbidity and mortality. Identification of high-risk factors may allow more rational patient selection or sequencing of therapy.

Underuse of Esophagectomy as Treatment for Resectable Esophageal Cancer

HYPOTHESIS Esophagectomy is underused as treatment for resectable stage I, II, and III esophageal cancers. DESIGN AND SETTING Retrospective cohort study using the Surveillance, Epidemiology, and End Results-Medicare linked database. PATIENTS We used the Surveillance, Epidemiology, and End Results database to identify persons 65 years or older who were not enrolled in a health maintenance organization and who were diagnosed as having stage I, II, or III esophageal cancer between January 1, 1997, and December 31, 2002 (N = 2386). MAIN OUTCOME MEASURES The rate of surgical intervention was compared across varying patient characteristics, including age, race, comorbidity score, sex, tumor stage, and socioeconomic region. Survival was compared between patients who received surgery and those who did not using Kaplan-Meier curves, the log-rank test, and Cox proportional hazards regression. Statistical analysis was performed using the chi2 test and multiple logistic regression. RESULTS The overall rate of surgical intervention in this cohort was 34.1%. In all, 36.8% of white patients underwent surgical treatment of their disease, whereas only 19.2% of nonwhite patients did. Patients residing in areas with high poverty rates were 27% less likely to have surgery. Older age and higher comorbidity scores were also associated with lower rates of surgery. Patients who received surgical treatment for their disease experienced significantly longer survival than did patients who did not undergo surgical resection. CONCLUSIONS There seems to be significant underuse of esophagectomy as treatment for potentially resectable stage I, II, and III esophageal cancers across all patient groups. In nonwhite and low socioeconomic patient cohorts, the underuse is even more pronounced.

Time-of-Day Effects on Surgical Outcomes in the Private Sector: A Retrospective Cohort Study

BACKGROUND Surgical care is delivered around the clock. Elective cases within the Veterans Affairs health system starting after 4 pm appear to have an elevated risk of morbidity, but not mortality, compared with earlier cases. The relationship between operation start time and patient outcomes is not described in private-sector patients or for emergency cases. STUDY DESIGN We performed a retrospective cohort study of 56,920 general and vascular surgical procedures performed from October 2001 through September 2004, and entered into the National Surgical Quality Improvement Program database. Operation start time was the independent variable of interest. Random effects, hierarchical logistic regression models adjusted for patient, operative, and facility characteristics. Two independent models determined associations between start time and morbidity or mortality. Subset analysis was performed for emergency and nonemergency cases. RESULTS After adjustment for patient and procedure characteristics, mortality had a moderately strong association with start time, but only for nonemergency cases starting 9:30 pm to 7:30 am (odds ratio = 1.752; p = 0.028; reference 7:30 am to 9:30 am). As for morbidity, after adjustment, operations starting 9:30 am to 1:30 pm and 5:30 pm to 9:30 pm were associated with a weakly elevated risk of morbidity, but those starting 9:30 pm to 7:30 am demonstrated a strong effect on morbidity (odds ratio = 1.32; p < 0.0001). Subgroup analysis showed this effect was largely a result of elevated risk of morbidity in emergency cases from this overnight time period (odds ratio = 1.48; p = 0.001). CONCLUSIONS Surgical start times are associated with risk-adjusted patient outcomes. In terms of facility operations management and resource allocation, consideration should be given to the capacity to accommodate cases with differences in risk during different time periods.