A Comparative Assessment of Surgeons’ Tracking Methods for Surgical Site Infections

Surg Infect (Larchmt) 2013;14(2):181-7.

Gabrielle H. van Ramshorst,1 Margreet C. Vos,2 Dennis den Hartog,1 Wim C.J. Hop,3 Johannes Jeekel,4 Steven E.R. Hovius,5 and Johan F. Lange1

1 Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.

2 Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.

3 Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands.

4 Department of Neuroscience, Erasmus University Medical Center, Rotterdam, The Netherlands.

5 Department of Plastic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.

 

Abstract

Background: The incidence of surgical site infections (SSI) is considered increasingly to be an indicator of quality of care. We conducted a study in which daily inspection of the surgical incision was performed by an independent, trained team to monitor the incidence of SSI using U.S. Centers for Disease Control and Prevention (CDC) definitions, as a goldstandard

measure of care. In the department of surgery, two registration systems for SSI were used routinely by the surgeon: An electronic and a plenary tracking system. The results of the independent team were compared with the outcomes provided by two registration systems for SSI, so as to evaluate the reliability of these systems as a possible alternative for indicating quality of care.

Methods: The study was an incidence study conducted from May 2007 to January 2009 that included 1,000 adult patients scheduled to undergo open abdominal surgery in an academic teaching hospital. Surgical incisions were inspected daily to check for SSI according to definitions of health care-associated infections established by the CDC. Follow-up 30 days after discharge was done at the outpatient clinic of the hospital by telephone or letter in combination with patient diaries and reviews of patient charts, discharge letters, electronic files, and reported complications. Incidence as defined by daily check of infections using CDC criteria, were compared to two complication-registration systems. Univariate and multivariable analyses were done to identify putative risk factors for missing registrations.

Results: Of the 1,000 patients in the study, 33 were not evaluated. Surgical site infections were diagnosed in 26.8% of the 967 remaining patients, of which 18.0% were superficial incisional infections, 5.4% were deep incisional infections, and 3.4% were organ/space infections. More than 60% of SSIs were unreported in either of the department’s two tracking systems for such infections. For these two systems, independent major risk factors for missing registrations were (1) no development of SSI, (2) transplantation surgery, and (3) admission to non-surgical departments.

Conclusions: Most SSIs were not scored by the department’s two systems. These systems proved poor alternatives to the gold-standard method of quantifying the incidence of  SSI and, therefore, the quality of care. Both protocolized wound assessment and on-site documentation are mandatory for realistic quantification of the incidence of SSI.

 

Additional information

Infections related to surgical wounds can range from small superficial infection of the skin to severe abscess formation in spaces near abdominal organs such as the liver. It is thought that the incidence of such infections is an indicator of the quality of surgical care. In our study, patients with surgical wounds underwent daily inspection by a team (‘gold standard’ method). The members of this team were not influenced by surgeons who performed the operations. The number and severity of infected surgical wounds were monitored by the team, using standard international definitions1. Surgeons in the Netherlands are obliged to register (track) surgery-related complications. In our Department of Surgery, two registration systems were routinely used for this purpose: an electronic system and a plenary tracking system. Data collected by the trained team were compared to data collected in the department’s registration systems. Using this method, the reliability of these systems was evaluated to establish whether these systems could be alternatives for indicating quality of care.

The study was an incidence study conducted from May 2007 to January 2009 in an academic teaching hospital. A total number of 1000 adult patients who were scheduled to undergo open abdominal surgery participated in this study. Patients with surgical wounds underwent daily inspection by the aforementioned team. After discharge, patients used diaries to note wound problems. Thirty days after surgery, patients underwent check-ups at the outpatient clinic, or were contacted by telephone or letter. Patient charts, discharge letters, electronic files, and reported complications were reviewed for all patients. Statistical analysis was performed to find out why no data were found in the department’s registration systems for some patients.

Of the 1,000 patients who participated in the study, 33 could not be evaluated for various reasons. Infections related to surgical wounds were diagnosed in 26.7% of the 967 remaining patients. These infections were related to superficial wounds in 18.0%, deep wounds in 5.4%, and related to spaces near abdominal organs in 3.4%. More than 60% of SSI  were not reported in either of the department’s two tracking systems for these infections. If no data were found for patients in the registration systems, it was likely that these patients had not developed any wound-related infections, had undergone transplantation surgery or had been admitted to another hospital department.

Most infections related to surgical wounds were not tracked using the department’s two registration systems. These systems proved too unreliable to replace the gold standard method for measuring incidence of wound-related infections or quality of care. For realistic measurement of incidence of wound-related infections, wounds need to be inspected using standard protocol and infections need to be documented on-site.

 

References

1 Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: A modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606–608.

 

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