POST-OPERATIVE WOUND INFECTION

Transcription

1 POST-OPERATIVE WOUND INFECTION IN AMBULATORY SURGERY: IMPACT, BURDEN, AND STRATEGIES FOR IMPROVEMENT Nicholas Costanzo MS3

2 OVERVIEW Definitions Epidemiology Cost Guidelines Pre-op Factors Immediate Peri-operative Factors Post-op Management Limitations and Access Future Directions

3 DEFINITIONS What is Ambulatory surgery and what is a Surgical Site infection?

4 DEFINITIONS Ambulatory Surgery: Any surgery in which the patient both undergoes the procedure and is discharged from the surgical center/hospital in the same day. No overnight hospital stay is necessary. The same procedures may be ambulatory for a low risk population and inpatient for a high risk population Procedures such as endoscopy are often included in statistics regarding ambulatory surgery

5 DEFINITIONS Surgical Site Infection: Infections that begin locally, within 30 days of an operation at the surgical site. CDC defines severity based on the depth of the infection at the surgical site. Either Incisional or Organ Space CDC definitions are not used when discussing episiotomy, circumcision, or burn wounds Other, more broad, definitions are used in the literature; those requiring IV vs PO antibiotics. This results in inaccurate and underreporting of SSI

6 CDC DEFINITIONS OF SSI

7 EPIDEMIOLOGY What current data is available regarding trends in ambulatory surgery, SSI following ambulatory surgery, and risk factors associated with SSI?

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9 EPIDEMIOLOGY: AMBULATORY SURGERY Estimated 75% of all operations performed fall into the Ambulatory category 57.1 million ambulatory surgeries and procedures performed in 2006 alone Over 10 million endoscopic procedures, including Colonoscopy w/ or w/o polypectomy Upper Endo w/ or w/o biopsy Over 7 million orthopedic procedures Over 1.3 million cardiovascular procedures, including Cardiac Catheterization Over 900,000 hernia repairs Over 500,000 lap cholecystectomy

10 EPIDEMIOLOGY: AMBULATORY SURGERY Between 1996 and 2006 there was a 300% increase in the number of procedures performed at free-standing Surgical Centers The predominance of the hospital based setting continued in 2010

11 EPIDEMIOLOGY: SSI IN AMBULATORY SURGERY SSI rates vary based on surgical procedure SSI following herniorrhaphy % SSI following varicose vein procedures 1.5% SSI following breast biopsy 1.58% SSI following Arthroscopy 0.4%

12 EPIDEMIOLOGY: PATIENT SPECIFIC RISK FACTORS Patient characteristics shown to increase SSI: Age Malnutrition DM Smoking Obesity Infection present at remote location Bacterial colonization Impaired immunity

13 EPIDEMIOLOGY: SOCIOECONOMIC INFLUENCES Influence of Private Insurance: Private insurance has been shown as an independent predictor of decreased SSI in patients 65 years and greater Odds Ratio for patients with private insurance to get a SSI was 0.29 (p.005)

14 COST What are the costs of SSI?

15 ESTIMATED COSTS OF SSI Direct Financial Burden of SSI varies widely Superficial SSI: Est. $ for resolution Major SSI: Est. $30, for resolution Est based on 2006 data Indirect Costs are difficult to access Lost productivity Temporary/permanent impairment Decreased patient satisfaction Decreased referral volume Litigation related expenses/time

16 GUIDELINES What guidelines are currently regarding Surgical Site infection prevention are available?

17 CURRENT GUIDELINES IN SSI PREVENTION AS OUTLINED BY THE CDC Pre-operative Risk Stratification Previously outlined and to be expanded upon Operative Characteristics Antiseptic Showering Pre-op hair removal Skin Prep Proper scrubbing Staff management AMP (Antimicrobial Prophylaxis) Environmental Issues (OR, Attire, Ventilation Systems)

18 CURRENT GUIDELINES IN SSI PREVENTION AS OUTLINED BY THE CDC Post-operative Issues: Incision Care Discharge Planning SSI Surveillance

19 PRE-OP RISK FACTORS What are some modifiable risk factors which can decrease SSI in Ambulatory Surgery and what resources are available in changing these health practices?

20 OBESITY AND SSI Raised BMI (30 or greater) has been shown to increase the risk of SSI following Ambulatory Surgery Odds ratio of (p.001) for groin surgical site infection following varicose vein surgery

21 RESOURCES TO REDUCE WEIGHT 11 South Road, Suite 130, Farmington CT ( ) Multidisciplinary approach; includes TakeOff: Medically monitored very-low calorie diet CORE: 12 week educational program addressing nutrition, physical activities, and psychological/behavioral weight loss barriers Nutritional Counseling Bariatric Surgery Newington Weight Watchers Center; 26 Fenn Rd, Newington CT ( ) A weight management support group with frequent meetings and weight checks Provides strategies as well as motivational support for group members Cost is variable based on duration of attendance and incentivized based on achievement of weight loss goals

22 SMOKING AND SSI Peri-operative smoking has been shown to increase the risk of SSI following Ambulatory Surgery Odds ratio of 16.3 (p.019) for SSI in smokers undergoing a variety of Ambulatory Surgeries; including General Orthopedic Plastics Gynecological Other Overall SSI rate of 3.6% Smoking cessation interventions have shown a significant decrease in SSI Odds ratio of.43 as compared to no cessation interventions

23 RESOURCES TO QUIT SMOKING Smokefree.gov A government managed website with a number of smoking cessation tools; including Links to expert advice A step by step guide based on Readiness to Quit A smoking cessation text message system which provides instant feedback, support, and advice for participants Tobacco Use Prevention & Control Program 410 Capitol Ave, Hartford CT CT DPH sponsored program includes CT Quitline (1-800-QUIT-NOW) Informative Pamphlets Free Stats and Report Documents

24 IMMEDIATE PERI-OPERATIVE PRACTICES What practices on the day of Surgery and while in the OR can prevent SSI?

25 ANTIMICROBIAL PROPHYLAXIS AMP Works in Ambulatory Surgery Odds ratio for varicose vein surgery patients receiving prophylactic antibiotics to get a SSI was 0.54 (p.02) Four Principles of AMP AMP has been shown effective to reduce SSI in all surgeries for which a organ space or incisional SSI could be deemed catastrophic AMP should be performed with a bactericidal, broad spectrum, inexpensive, and widely available agent AMP needs to be administered at such a time that serum levels are therapeutic at time of incision AMP therapeutic levels must be maintained through the duration of the procedure and for several hours after the surgical wound is closed. Antibiotic choice and timing is dependant on operative procedure and likely infectious organisms

26 POST-OP MANAGEMENT What resources and health care practices are available to help decrease SSI rate and/or reduce the burden of post-op recovery on the Patient?

27 POST-OP MANAGEMENT Post-op Surgical Site Care Post-operative wound care and infection surveillance is easily performed with inpatient surgery Ambulatory surgery poses the hurdle of the generally lay population providing this difficult service Dressing changes Wound care Administration of medication Identify and report adverse event Topical Treatment of Surgical Wounds Wound dressing with Bacitracin ointment shows no significant difference in SSI rates when compared to wound dressings with petroleum ointment Incidence of Staph. infection lower in Bacitracin ointment group

28 IMPROVING SURVEILLANCE AND WOUND CARE No single recommendation by CDC Complex systems of frequent at home visits and biweekly visits to the surgeon have been shown to be effective (nearly 100%) at identifying SSI Simple questionnaires tend to be ineffective Home mailed surveys to patients detection rates of 15-33% Available Organization CT VNA 103 Woodland Street, Hartford,CT ( )

29 LIMITATIONS What are the limitations to our previous discussion?

30 COST AND ACCESS As outlined previously socio-economic status, represented by insurance coverage, impacts the incidence of SSI Furthermore, some of the community and healthcare resources outlined require both insurance coverage and/or out of pocket expense A 12 week Weight Watchers Course can cost $ VNA requires Medicare/Insurance approval or extraordinary out of pocket expenses

31 FUTURE DIRECTIONS With the knowledge we have what can (should) be done in the future to reduce SSI risk?

32 FUTURE DIRECTIONS: PATIENTS Patient education needs to be improved Empowerment of patients regarding weight loss and smoking cessation can reduce the burden of SSI Delay of elective procedures to optimize the patient needs to be Cost and approval process of VNA type services are prohibitive for most

33 FUTURE DIRECTIONS: CARE PROVIDERS An interdisciplinary approach beyond the OR Surgeon Anesthesiologist PCP A huge majority of peri-operative management falls on the shoulders of PCP Patient health optimization Pre-op clearance Identification of SSI Long-term post-op care A more explicit PCP role in the surgical process could potentially: Improve patient continuity Improve care-coordination between specialists Streamline the pre-op process Bring a more holistic approach to peri-operative care

34 REFERENCES Cullen, K. (2009). Ambulatory Surgery in the United States, National Health Statistics Reports, 11, 1-28 A valuable resource which reviewed epidemiological data regarding ambulatory surgery in the United States during Hirsemann, S. et. al (2005). Risk factors for surgical site infections in a free-standing outpatient setting. American Journal of Infection Control and Epidemiology, 33, A valuable resource that highlighted SSI in hernia repair and varicose vein surgeries in a free standing surgical center. Kaye, K. (206). Risk Factors for Surgical Site Infections in Older People. Journal of the American Geriatrics Society, 54, A resource that highlighted a number of risk factors associated specifically with elderly surgical patients. Gave insight into the impact of socioeconomic status and SSI. Larson, E. et. al (1999). GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, Infection control and Hosptial Epidemiology, 20(4), An extremely valuable and widely utilized resource reviewing definitions of SSI, risk factors associated with SSI, methods of preventing SSI, and current standards in practice. Compiled a great deal of literature. Myles, P. S. (2002). Risk of Respiratory Complications and Wound Infection in Patients Undergoing Ambulatory Surgery. Smokers vs Non-smokers Anesthesiology, 97, A very valuable resource that highlighted a number of negative surgical outcomes associated with smoking. Most importantly it highlighted the profound elevation of SSI likelihood in smokers. Wiwanitki, V.(2008). Raised BMI is an independent risk factor for groin surgical site infections in patients undergoing varicose vein surgery. American Journal of Infection Control, NA, A very valuable resource which highlighted the increased likelihood of SSI of an extremely common outpatient surgical procedure in the obese population.

35 REFERENCES Rey, J. et. al (2005). Determinants of surgical site infection after breast biopsy. American Journal of Infection Control and Epidemiology, 33, A resource which identified SSI rates in breast biopsies, a common outpatient surgical procedure. Singh, R. et. al (2012). Benefit of a Single Dose of Preoperative Antibiotic on Surgical Site Infection in Varicose Vein Surgery. Annals of Vascular Surgery, NA, 1-8. A valuable resource which outlined the effectiveness and importance of preoperative AMP in a common outpatient surgical procedure. Smack, D. et. al (1996). Infection and Allergy Incidence in Ambulatory Surgery Patients Using White Petrolatum vs Bacitracin Ointment. JAMA, 276, A valuable resource which outlined the importance of postoperative wound care. Made an important statement regarding the similar efficacy of both petroleum jelly and Bacitracin ointment in preventing SSI. It also highlighted the decrease in incidence of Staph infections with Bacitracin. Sørensen, L. (2012). Wound Healing and Infection in Surgery. Archives of Surfery, 147(4), A review paper which outlined the importance of smoking cessation in surgical outcomes and the prevention of SSI. Referenced specific evidence demonstrating that SSI rates were lower following a smoking cessation program. The paper also had in depth discussion regarding other surgical outcomes effected by smoking. Urban, J. (2006). Cost Analysis of Surgical Site Infections. Surgical Infections, 7, S A paper which reviewed general costs which can be both directly and indirectly associated with SSI. The paper did not focus exclusively on ambulatory surgery. Weight-Loss Programs. (2011). Weigh Your Options, THOCC. An informative brochure which outlined the Weigh Your Options program.