Hospital Outcomes in Inpatient Laparoscopic Cholecystectomy in Medicare Patients.

OBJECTIVE: To compare the risk-adjusted outcomes of hospitals in inpatient Medicare laparoscopic cholecystectomy. BACKGROUND: Reduced length-of-stay for inpatient surgical care requires the inclusion of objective postdischarge outcomes to provide a comprehensive assessment of hospital and surgeon performance for quality improvement. METHODS: The 2010 to 2012 Medicare Limited Data Set was used to develop risk-adjusted prediction models of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths, and 90-day readmissions for inpatient laparoscopic cholecystectomy. To define the opportunity for improved performance, prediction models were used to compute z scores and risk-adjusted adverse outcome rates for all hospitals in the database that had 20 or more evaluable cases for the study period. RESULTS: A total of 83,274 patients from 1570 hospitals had an overall adverse outcome rate of 20.7%; 48 hospitals had outcomes that were 2 z scores better than predicted and 76 had 2 z scores poorer than predicted. Risk-adjusted adverse outcomes were 10.0 % in the best performing decile of hospitals and were 32.1% in the poorest performing decile. Gastrointestinal, infectious, and cardiopulmonary complications of care were the most common causes of readmissions with 46.3% occurring between days 30 and 90 after discharge. CONCLUSIONS: Comparative analysis of overall risk-adjusted inpatient and 90-day postdischarge adverse outcomes identifies considerable opportunity for improved care in this high-risk population of patients.

Infection control in colon surgery.

PURPOSE: The aim of this study is to provide a comprehensive review of strategies that should be employed in the prevention of infection at the surgical site in patients undergoing colon surgery. METHODS: The world's literature on the pathogenesis and prevention of infections at the surgical site in colon resection were reviewed to identify those methods that are associated with improved rates of infection at the surgical site. The pathogenesis, microbiology, diagnosis, and surveillance of surgical site infection have been reviewed in the context of better understanding the accepted methods for prevention. Recommendations are provided based upon evidence-based information when available. RESULTS: Surgical site infection rates in colon surgery have been reduced consistently over the last 60 years of surgical practice. Preoperative and intraoperative techniques are described which have been useful in this improvement, while postoperative methods including the extension of postoperative systemic antibiotics have not been of value. CONCLUSIONS: Many methods have been demonstrated to improve surgical site infection rates in colon surgery. However, consistent and standardized applications of these principals in prevention currently do not exist. Application of evidence-based practices can further reduce the morbidity and cost of infection following colon surgery.

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery.

Surgical site infections (SSIs) are the most common adverse event occurring in surgical patients. Optimal prevention of SSIs requires the bundled integration of a variety of measures before, during, and after surgery. Surgical antibiotic prophylaxis (SAP) is an effective measure for preventing SSIs. It aims to counteract the inevitable introduction of bacteria that colonize skin or mucosa into the surgical site during the intervention. This document aims to guide surgeons in appropriate administration of SAP by addressing six key questions. The expert panel identifies a list of principles in response to these questions that every surgeon around the world should always respect in administering SAP.

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey.

BACKGROUND: The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. METHODS: A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. RESULTS: Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. CONCLUSION: Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.

Is there a role for bowel preparation and oral or parenteral antibiotics in infection control in contemporary colon surgery?

The numbers of unanswered questions are many. Can intraoperative application, such as topical antimicrobial use in pulsed lavage, reduce the microbial burden on the wound interface before closure? Can closed suction drains within the closed surgical incision reduce infection rates, especially in patients with a large body mass index? What is the role of delayed primary closure or secondary closure in the wound where obvious contamination has occurred, or in the circumstance of emergent colonic resection where considerable contamination is encountered from preexistent perforation? Should immediate negative-pressure wound dressings be applied in the open contaminated wound? These and many other questions still confront the surgeon in the challenge of the surgical wound in major colorectal surgery.

Defining Potentially Preventable Adverse Outcomes in Medicare Elective Lung Resections.

OBJECTIVE: The aims of the study were to develop risk-adjusted models and apply them for comparisons of hospital performance to define potentially preventable adverse outcomes (OAs) in Medicare lung resection surgery. METHODS: The Medicare Limited Data Set for 2010-2012 was used to design predictive risk models for the four OAs of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without hospital readmission, and 90-day readmissions after removal of unrelated readmission events. The probability of adverse events for each hospital was used to compute the hospital-specific standard deviation (SD) tailored to patient risk profiles. Observed versus predicted adverse events divided by the hospital-specific SD identified the z score for each hospital. Risk-adjusted OA rates were then computed for comparing hospital performance. RESULTS: A total of 39,405 lung resection patients from 739 hospitals had 768 inpatient deaths (1.9%), 3147 had prolonged LOS (8.0%), 514 had 90-day postdischarge deaths without readmission (1.3 %), and 7701 had one or more 90-day readmissions (19.5%); 10,924 patients (27.7%) had one or more of these OAs. Twenty-six hospitals were two SDs better than predicted and 34 hospitals were two SDs poorer than predicted. When evaluated by deciles of risk-adjusted OAs, the top performing decile of hospitals had rates of 14.3% and the poorest performing decile had OA rates of 41.0%. CONCLUSIONS: The differences in risk-adjusted comparative outcomes between top- and suboptimal-performing hospitals in lung resections define the potential opportunities for care improvement. Identification of risk factors associated with OAs and causes for readmissions provides direction for specific areas of care redesign for improvement.

Controlling costs without compromising quality: paying hospitals for total knee replacement.

BACKGROUND: Unit costs of health services are substantially higher in the United States than in any other developed country in the world, without a correspondingly healthier population. An alternative payment structure, especially for high volume, high cost episodes of care (eg, total knee replacement), is needed to reward high quality care and reduce costs. METHODS: The National Inpatient Sample of administrative claims data was used to measure risk-adjusted mortality, postoperative length-of-stay, costs of routine care, adverse outcome rates, and excess costs of adverse outcomes for total knee replacements performed between 2002 and 2005. Empirically identified inefficient and ineffective hospitals were then removed to create a reference group of high-performance hospitals. Predictive models for outcomes and costs were recalibrated to the reference hospitals and used to compute risk-adjusted outcomes and costs for all hospitals. Per case predicted costs were computed and compared with observed costs. RESULTS: Of the 688 hospitals with acceptable data, 62 failed to meet effectiveness criteria and 210 were identified as inefficient. The remaining 416 high-performance hospitals had 13.4% fewer risk-adjusted adverse outcomes (4.56%-3.95%; P < 0.001; χ) and 9.9% lower risk-adjusted total costs ($12,773-$11,512; P < 0.001; t test) than all study hospitals. Inefficiency accounted for 96% of excess costs. CONCLUSIONS: A payment system based on the demonstrated performance of effective, efficient hospitals can produce sizable cost savings without jeopardizing quality. In this study, 96% of total excess hospital costs resulted from higher routine costs at inefficient hospitals, whereas only 4% was associated with ineffective care.

Pro-Con Perspectives on Ethics in Surgical Research: Update from the 39th Annual Surgical Infection Society Meeting.

Background: Surgical research is potentially invasive, high-risk, and costly. Research that advances medical dogma must justify both its ends and its means. Although ethical questions do not always have simple answers, it is critically important for the clinician, researcher, and patient to approach these dilemmas and surgical research in a thoughtful, conscientious manner. Methods: We present four ethical issues in surgical research and discuss the opposing viewpoints. These topics were presented and discussed at the 39th Annual Meeting of the Surgical Infection Society as pro-con debates. The presenters of each opinion developed a succinct summary of their respective reviews for this publication. Results: The key subjects for these pro-con debates were: (1) Should patients be enrolled for time-sensitive surgical infection research using an opt-out or an opt-in strategy? (2) Should patients who are being enrolled in a randomized controlled trial (RCT) comparing surgery with a non-operative intervention pay the costs of their treatment arm? (3) Should the scientific community embrace open access journals as the future of scientific publishing? (4) Should the majority of funding go to clinical or basic science research? Important points were illustrated in each of the pro-con presentations and illustrated the difficulties that are facing the performance and payment of infection research in the future. Conclusions: Surgical research is ethically complex, with conflicting demands between individual patients, society, and healthcare economics. At present, there are no clear answers to these and the many other ethical issues facing research in the future. Answers will only come from continued robust dialogue among all stakeholders in surgical research.

A systems approach to the prevention of surgical infections.

Infection after surgery continues to be a major source of morbidity and expense despite extensive efforts with educational programs, guidelines, and hospital-based policies and procedures. The public and the government are demanding better performance and greater accountability. Our system operations within our institutions have failed. We need to adopt a culture dedicated to quality control through better information technology and data-driven initiatives to achieve improved clinical outcomes from infectious complications in surgery.

Modifying ICD-9-CM coding of secondary diagnoses to improve risk-adjustment of inpatient mortality rates.

OBJECTIVE: To assess the effect on risk-adjustment of inpatient mortality rates of progressively enhancing administrative claims data with clinical data that are increasingly expensive to obtain. Data Sources. Claims and abstracted clinical data on patients hospitalized for 5 medical conditions and 3 surgical procedures at 188 Pennsylvania hospitals from July 2000 through June 2003. METHODS: Risk-adjustment models for inpatient mortality were derived using claims data with secondary diagnoses limited to conditions unlikely to be hospital-acquired complications. Models were enhanced with one or more of 1) secondary diagnoses inferred from clinical data to have been present-on-admission (POA), 2) secondary diagnoses not coded on claims but documented in medical records as POA, 3) numerical laboratory results from the first hospital day, and 4) all available clinical data from the first hospital day. Alternative models were compared using c-statistics, the magnitude of errors in prediction for individual cases, and the percentage of hospitals with aggregate errors in prediction exceeding specified thresholds. RESULTS: More complete coding of a few under-reported secondary diagnoses and adding numerical laboratory results to claims data substantially improved predictions of inpatient mortality. Little improvement resulted from increasing the maximum number of available secondary diagnoses or adding additional clinical data. CONCLUSIONS: Increasing the completeness and consistency of reporting a few secondary diagnosis codes for findings POA and merging claims data with numerical laboratory values improved risk adjustment of inpatient mortality rates. Expensive abstraction of additional clinical information from medical records resulted in little further improvement.

Operating Room Hand Preparation: To Scrub or to Rub?

BACKGROUND: The alcohol rub has been proposed as an alternative to the traditional surgical scrub in preparing the hands for surgical procedures. Few reviews have examined critically the evidence that favors or discredits the use of the alcohol rub instead of the traditional scrub. METHODS: A review of available published literature was undertaken to define the evidence for the best methods for hand preparation before surgical procedures. The focus of this literature review was to compare the bacteriologic and clinical outcomes of conventional surgical scrubbing of the hands compared with alcohol rubs. RESULTS: The bacteriologic studies of the hands after the conventional scrub versus the alcohol rub demonstrated consistently comparable or superior reductions in bacterial presence on the hand with the alcohol rub. Only four clinical studies were identified that compared the scrub versus the rub in the frequency of surgical site infections. No difference in surgical site infections were identified. CONCLUSIONS: The alcohol rub appears to have comparable results to the surgical scrub and is a reasonable alternative in preparation of the hands for surgical procedures.

Inpatient and Postdischarge Outcomes Following Elective Craniotomy for Mass Lesions.

BACKGROUND: Interpretation of hospital quality requires objective evaluation of both inpatient and postdischarge adverse outcomes (AOs). OBJECTIVE: To develop risk-adjusted predictive models for inpatient and 90-d postdischarge AOs in elective craniotomy and apply those models to individual hospital performance to provide benchmarks to improve care. METHODS: The Medicare Limited Dataset (2012-2014) was used to define all elective craniotomy procedures for mass lesions in patients ≥65 yr. Predictive logistic models were designed for inpatient mortality, inpatient prolonged length of stay, 90-d postdischarge deaths without readmission, and 90-d readmissions after exclusions. The total observed patients with one or more AOs were then compared to predicted AO values, and z-scores were computed for each hospital that met minimum volume requirements. Risk-adjusted AO rates allowed stratification of eligible hospitals into deciles of performance. RESULTS: The hospital evaluation was performed for 223 facilities with 7624 patients that met criteria. A total of 849 patients (11.1%) died inclusive of 90 d postdischarge; 635 (8.3%) were 3σ length-of-stay outliers; and 1928 patients (25.3%) with one or more 90-d readmissions; 2716 patients experienced one or more AOs (35.6%). Six hospitals were 2 z-scores better than average, and 8 were 2 z-scores poorer. The median risk-adjusted AO rate was 18% for the first decile and 53.4% for the 10th decile. CONCLUSION: There was a 35% difference between best and suboptimal performing hospitals for this operation. Hospitals must know their risk-adjusted AO rates and benchmark their results to inform processes of care redesign.

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients.

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

A "health commons" approach to oral health for low-income populations in a rural state.

Oral health needs are urgent in rural states. Creative, broad-based, and collaborative solutions can alleviate these needs. "Health commons" sites are enhanced, community-based, primary care safety net practices that include medical, behavioral, social, public, and oral health services. Successful intervention requires a comprehensive approach, including attention to enhancing dental service capacity, broadening the scope of the dental skills of locally available providers, expanding the pool of dental providers, creating new interdisciplinary teams in enhanced community-based sites, and developing more comprehensive oral health policy. By incorporating oral health services into the health commons primary care model, access for uninsured and underserved populations is increased. A coalition of motivated stakeholders includes community leaders, safety net providers, legislators, insurers, and medical, dental, and public health providers.

Preventive systemic antibiotics in colorectal surgery.

BACKGROUND: Elective colon surgery has the highest rate of surgical site infection (SSI) of any elective procedure in surgery. The evolution of strategies for the prevention of SSI has had the correct use of preventive antibiotics as a crucial component. METHODS: Review of the pertinent English-language literature. RESULTS: Correct use of prophylactic antibiotics in elective colon surgery requires that the drug have activity against colonic aerobic and anaerobic bacteria, be administered immediately before the surgical incision, and not be continued into the postoperative period. All of the documented and many of the theoretically feasible antibiotic choices are discussed in terms of their advantages for this indication. CONCLUSIONS: The best outcomes in the prevention of SSI in elective colon surgery are achieved when appropriate systemic antibiotics are employed in conjunction with the appropriate use of oral antibiotic bowel preparation.

Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures.

BACKGROUND: Surgical site infection (SSI) continues to be a common if often times preventable infection. Considerable patient morbidity and economic cost are the consequences. METHODS: Review of the pertinent English-language literature. RESULTS: The National Surgical Infection Prevention (SIP) Project was an initiative sponsored jointly by the Centers for Medicare and Medicaid Services and the U.S. Centers for Disease Control and Prevention to decrease the incidence of SSI in major surgical procedures. Three performance measures were developed to improve the timing of antibiotic administration and the selection of the drug and to reduce needless postoperative administration of antibiotics. The success of SIP led to the Surgical Care Improvement Project (SCIP), which is expanding performance measures in the area of prevention of SSI, and also is undertaking preventive measures against postoperative venous thromboembolism and cardiac events. Federal legislation has required hospitals to report rates of compliance with many of these process measures. CONCLUSIONS: Surgeons must use all documented strategies to prevent SSIs.

Antimicrobial Peptides.

BACKGROUND: Bacterial resistance to available antibiotics has resulted in enhanced efforts at antibiotic stewardship but also has led to investigation into alternative methods for managing surgical infections. Antimicrobial peptides (AMPs) are naturally occurring compounds produced by all prokaryotic and eukaryotic cells that have potential as an alternative to conventional antibiotics. METHODS: The published literature was reviewed for investigations that were relevant to infections commonly seen by surgeons and the potential applicability of AMPs for surgical care. RESULTS: Antimicrobial peptides are low-molecular-weight peptides with activity against bacteria, fungi, and viruses. Experimental evidence shows that AMPs have activity against highly resistant bacteria identified from human infections. Furthermore, these peptides can be designed as semi-synthetic or totally synthetic constructs for potential clinical use. Antimicrobial peptides appear to have in vivo activity in limited animal studies, but the experimental models for evaluation of these peptides need more clinical relevance. These products are in clinical evaluation at present but are limited in number and are being evaluated primarily for topical applications. CONCLUSIONS: Antimicrobial peptides have considerable in vitro evidence that supports their use for the prevention and treatment of surgical infections. Better experimental and clinical trial efforts are needed to move this technology toward applicability in surgical care.