International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty.

BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

International Delphi Study on Wound Closure and Dressing Management in Joint Arthroplasty: Part 1: Total Knee Arthroplasty.

BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.

Increasing Incremental Burden of Surgical Bleeding Associated with Multiple Comorbidities as Measured by the Elixhauser Comorbidity Index: A Retrospective Database Analysis.

Purpose: Disruptive bleeding can complicate surgical procedures, increasing resource use, and impacting patients' well-being. This study aims to elucidate the impact of comorbidity on the risk of disruptive surgical-related bleeding and selected transfusion-associated complications, as well as the incremental cost of such bleeding. Patients and Methods: This retrospective analysis of the Premier Healthcare Database included patients who were age ≥18 years and who had a procedure of interest between 1-Jan-2019-31-Dec-2019: cholecystectomy, coronary artery bypass grafting, cystectomy, hepatectomy, hysterectomy, pancreatectomy, peripheral vascular, thoracic, and valve procedures (first=index). The Elixhauser comorbidity index was assessed on index date and patients were grouped by cumulative comorbidity score (0, 1, 2, 3, 4, 5, ≥6). Outcomes, all measured as in-hospital during index, included bleeding (diagnosis and/or intervention for bleeding), transfusion-associated complications (diagnosis of infection, acute renal failure, or vascular events), and incremental total hospital costs associated with bleeding. Multivariable generalized linear models were used to examine the association of comorbidity/bleeding with outcomes. Results: Of the 304,074 patients included, 7% experienced bleeding. The Elixhauser scores were distributed as follows: 0=29%, 1=23%, 2=18%, 3=12%, 4=8%, 5=5%, ≥6=5%. Odds of bleeding significantly increased with Elixhauser score: 1 comorbidity vs 0 (odds ratio [OR] =1.30, 95% confidence interval [95% CI] =1.19-1.43), and this trend continued to surge (≥6 comorbidities [OR=3.22, 95% CI=2.94-3.53]). Similarly, the odds of transfusion-associated complications significantly increased with comorbidities score: 1 comorbidity vs 0 (OR=2.14, 95% CI=1.88-2.34), ≥6 comorbidities vs 0 (OR=12.37, 95% CI=10.80-14.16). The incremental cost of bleeding also increased with comorbidities score; per-patient costs with and without bleeding were $18,132 vs $13,190, p < 0.001 among patients with 0 comorbidities and $28,952 vs $19,623, p < 0.001 among patients with ≥6 comorbidities. Conclusion: Higher comorbidity burden was associated with significant increases in the risk of surgical bleeding, subsequent transfusion-related complications, and incremental cost burden of bleeding.

Isolating and characterizing cluster AB Mycobacteriophage NoShow, which encodes lysis proteins shared with cluster H2 phages.

We present here Mycobacteriophage NoShow, isolated from a soil sample collected on the Maguire Campus of Saint Joseph's University in Merion Station, Pennsylvania. Even though NoShow's 52,825 bp genome is most similar to phages in cluster AB, its lysA and lysB genes are most similar to phages in cluster H2.

Clinical and Economic Burden Associated with Disruptive Surgical Bleeding: A Retrospective Database Analysis.

Background: Hemostatic agents are used to control surgical bleeding; however, some patients experience disruptive bleeding despite the use of hemostats. In patients receiving hemostats, we compared clinical and economic outcomes between patients with vs without disruptive bleeding during a variety of surgical procedures. Methods: This was a retrospective analysis of the Premier Healthcare Database. Study patients were age ≥18 with a hospital encounter for one of 9 procedures with evidence of hemostatic agent use between 1-Jan-2019 and 31-Dec-2019: cholecystectomy, coronary artery bypass grafting (CABG), cystectomy, hepatectomy, hysterectomy, pancreatectomy, peripheral vascular, thoracic, and valve procedures (first procedure = index). Patients were grouped by presence vs absence of disruptive bleeding. Outcomes evaluated during index included intensive care unit (ICU) admission/duration, ventilator use, operating room time, length of stay (LOS), in-hospital mortality, and total hospital costs; 90-day all-cause inpatient readmission was also evaluated. Multivariable analyses were used to examine the association of disruptive bleeding with outcomes, adjusting for patient, procedure, and hospital/provider characteristics. Results: The study included 51,448 patients; 16% had disruptive bleeding (range 1.5% for cholecystectomy to 44.4% for valve). In procedures for which ICU and ventilator use is not routine, disruptive bleeding was associated with significant increases in the risks of admission to ICU and requirement for ventilator (all p≤0.05). Across all procedures, disruptive bleeding was also associated with significant incremental increases in days spent in ICU (all p≤0.05, except CABG), LOS (all p≤0.05, except thoracic), and total hospital costs (all p≤0.05); 90-day all-cause inpatient readmission, in-hospital mortality, and operating room time were higher in the presence of disruptive bleeding and varied in statistical significance across procedures. Conclusion: Disruptive bleeding was associated with substantial clinical and economic burden across a wide variety of surgical procedures. Findings emphasize the need for more effective and timely intervention for surgical bleeding events.

Effectiveness versus Uptake: The Challenges of Implementing Evidence-Based Strategies to Reduce Surgical Site Infection in Patients with Colon Surgeries.

Background: National and international recommendations for the prevention of surgical site infection (SSI) were published six years ago, but little is known about implementation in colon surgeries. Methods: We conducted an observational study to evaluate the implementation of seven SSI-prevention elements in colon surgeries. Study coordinators recorded the implementation using an electronic case report. Surgeons completed a survey that identified key drivers of implementation. Three peer-to-peer calls and a study coordinator survey provided insights on the obstacles and drivers to implementation. Results: The elements ranged in compliance from 100% to below 1%. Absence of documentation in the electronic medical record (EMR), conflicting local policies, and a lack of standardization of processes and products were significant obstacles in implementation. Discussion: Standardizing peri-operative procedures may be accomplished by implementing guidelines. Using implementation science to reduce variability and stocking leads to product standardization with items that support evidence-based practices. Administration, material management, and surgical leadership all have a duty to the patient to reduce obstacles to implement evidence-based practices. Conclusions: Our study reveals variability in in the integration of published guidelines into clinical practice. Every surgical patient deserves the best possible care by using evidence-based guidelines and practices centered on reducing SSIs.

Goals, challenges and strategies for wound and bleeding management in total knee arthroplasty: A modified Delphi method.

BACKGROUND: Surgical techniques related to soft tissue management play critical roles in optimizing surgical outcomes and patient satisfaction in total knee arthroplasty (TKA). Despite the importance of wound closure and bleeding management approaches, no published guidelines/consensus are available. METHODS: Twelve orthopedic surgeons participated in a modified Delphi panel consisting of 2 parts (each part comprising two rounds) from September-October 2018. Questionnaires were developed based on published evidence and guidelines on surgical techniques/materials. Questionnaires were administered via email (Round 1) or at a face-to-face meeting (subsequent rounds). Panelists ranked their agreement with each statement on a five-point Likert scale. Consensus was achieved if ≥70% of panelists selected 4/5, or 1/2. Statements not reaching consensus in Round 1 were discussed and repeated or modified in Round 2. Statements not reaching consensus in Round 2 were excluded from the final consensus framework. RESULTS: Consensus was reached on 13 goals of wound management. Panelists agreed on 38 challenges and 71 strategies addressing surgical techniques or wound closure materials for each tissue layer, and management strategies for blood loss reduction or deep vein thrombosis prophylaxis in TKA. Statements on closure of capsular and skin layers, wound irrigation, dressings and drains required repeat voting or modification to reach consensus. CONCLUSION: Consensus from Asia-Pacific TKA experts highlights the importance of wound management in optimizing TKA outcomes. The consensus framework provides a basis for future research, guidance to reduce variability in patient outcomes, and can help inform recommendations for wound management in TKA.

Real-world economic and clinical outcomes associated with current hemostatic matrix use in spinal surgery.

Aim: Bleeding during spine surgery is controlled using topical hemostatic agents. Studies have reported outcomes between Surgiflo® and Floseal, the most widely used flowable hemostatic matrices, but have not included the latest Surgiflo formulation which is more adherent to the bleeding surface than prior formulations. Materials & methods: A propensity score-matched analysis was conducted using the Premier Healthcare Database to compare economic and clinical outcomes of adults undergoing inpatient spinal surgery between 2013 and 2018 receiving current Surgiflo or Floseal. Results: This retrospective study included 28,910 patients in each group and found comparable outcomes for bleeding events, overall transfusion rate, inpatient mortality and readmissions between Surgiflo and Floseal. Surgiflo was associated with $430 (USD) lower hospitalization costs, shorter length of stay and shorter operating room time than Floseal.

Topical hemostatic agents such as Surgiflo^® and Floseal are used during invasive surgery to manage bleeding. We compared outcomes of spine surgeries that used either of two most frequently used topical hemostatic agents, Surgiflo or Floseal. This is the largest retrospective study presenting economic and clinical outcomes of patients receiving Surgiflo versus Floseal during spine surgery using the latest product formulations. The study suggests that clinical outcomes are comparable between Surgiflo and Floseal groups and that Surgiflo is associated with lower hospitalization costs, slightly shorter hospital stay and shorter operating room time among patients undergoing spine surgery.

Real-World Clinical and Economic Outcomes Associated with Surgiflo® vs Floseal in Cardiovascular Surgeries in the US.

Background: Topical hemostatic agents are an option for controlling bleeding during cardiovascular surgery. Previous studies comparing topical hemostatic agents in cardiovascular surgery predate the 2012 reformulation of Surgiflo®, which had been re-engineered to increase paste viscosity and thus be more adherent to the bleeding surface. Objective: To compare clinical and economic outcomes in patients receiving the current formulation of Surgiflo vs Floseal during cardiovascular surgeries. Methodology: A retrospective analysis was conducted using the Premier Healthcare Database. Eligible patients had an inpatient cardiovascular surgery between 1/1/2013 and 6/1/2018, were ≥18 years old and received the current formulation of Surgiflo or Floseal during surgery. Propensity score matching was performed, with exact matching on the surgery year and surgery type (aortic, coronary artery bypass grafting, valve, or other). Descriptive analysis and generalized estimating equations models compared outcomes between the Surgiflo and Floseal groups. Results: The matched sample included 5768 patients in each group (mean age: 66.5 years; 66.3% male). In the matched sample, rates of any documented bleeding event were similar in Surgiflo and Floseal groups (6.9% vs 7.2%; P = 0.576). Differences in transfusion rates between patients receiving Surgiflo vs Floseal varied by operational definition and timing of measurement but did not differ by >2 percentage points. Compared to Floseal, patients who received Surgiflo experienced longer surgery duration (306.0 vs 299.4 minutes), lower hospitalization cost ($44,146 vs $46,812), and lower odds of readmission at 30, 60, and 90 days post-discharge (all P < 0.05). Inpatient mortality and LOS were comparable between Surgiflo and Floseal (all P > 0.05). Conclusion: In this large study of real-world clinical and economic outcomes after cardiovascular surgery involving the current formulation of Surgiflo vs Floseal, Surgiflo was associated with mostly similar clinical outcomes as compared with Floseal. Differences in selected economic/resource use outcomes were also observed, for which root-cause analysis in future research would be informative.

Association of In-Hospital Surgical Bleeding Events with Prolonged Hospital Length of Stay, Days Spent in Critical Care, Complications, and Mortality: A Retrospective Cohort Study Among Patients Undergoing Neoplasm-Directed Surgeries in English Hospitals.

PURPOSE: To evaluate the association of in-hospital surgical bleeding events with the outcomes of hospital length of stay (LOS), days spent in critical care, complications, and mortality among patients undergoing neoplasm-directed surgeries in English hospitals. PATIENTS AND METHODS: This is a retrospective cohort study using English hospital discharge data (Hospital Episode Statistics [HES]) linked to electronic health records (Clinical Practice Research Datalink [CPRD]). HES includes information on patient demographics, admission and discharge dates, diagnoses and procedures, days spent in critical care, and discharge status. CPRD includes information on patient demographics, diagnoses and symptoms, drug exposures, vaccination history, and laboratory tests. Patients aged ≥18 years who underwent selected neoplasm-directed surgeries between 1-Jan-2010 and 29-February-2016: hysterectomy, low anterior resection (LAR), lung resection, mastectomy, and prostate surgery were included. The primary independent variable was in-hospital surgical bleeding events identified by diagnosis of haemorrhage and haematoma complicating a procedure or reopening/re-exploration and surgical arrest of postoperative bleeding. Outcomes included LOS, days spent in critical care, in-hospital complications (diagnoses of infections, acute renal failure, vascular events), and in-hospital mortality, identified during surgery through discharge. Multivariable regression was used to examine the adjusted association of bleeding events with outcomes. RESULTS: The study included 26,437 neoplasm-directed surgeries (hysterectomy=6092; LAR=2957; lung=1538; mastectomy=12,806; prostate=3044). Incidence proportions of bleeding events were: hysterectomy=1.9% (95% confidence interval=1.1-2.5%); LAR=3.0% (CI=2.3-3.6%); lung=1.8% (CI=1.1-2.5%); mastectomy=1.6% (CI=1.3-1.8%); prostate=1.0% (CI=0.6-1.3%). In adjusted analyses, bleeding events were associated with: prolonged LOS: 3.1 (CI=1.1-6.3) mastectomy to 5.7 (CI=3.6-8.2) LAR days longer; more days spent in critical care: 0.4 (CI=0.03-0.27) mastectomy to 6.5 (CI=2.5-13.6) hysterectomy days more; and higher incidence proportions of all examined complications; all P<0.05. CONCLUSION: This study quantifies a substantial clinical and healthcare resource utilization burden associated with surgical bleeding among patients undergoing neoplasm-directed surgery in England hospitals.

Impact of bleeding complications on length of stay and critical care utilization in cardiac surgery patients in England.

BACKGROUND: Bleeding is a significant complication in cardiac surgery and is associated with substantial morbidity and mortality. This study evaluated the impact of bleeding on length of stay (LOS) and critical care utilization in a nationwide sample of cardiac surgery patients treated at English hospitals. METHODS: Retrospective, observational cohort study using linked English Hospital Episode Statistics (HES) and Clinical Practice Research Datalink (CPRD) records for a nationwide sample of patients aged ≥18 years who underwent coronary artery bypass graft (CABG), valve repair/replacement, or aortic operations from January 2010 through February 2016. The primary independent variables were in-hospital bleeding complications and reoperation for bleeding before discharge. Generalized linear models were used to quantify the adjusted mean incremental difference [MID] in post-procedure LOS and critical care days associated with bleeding complications, independent of measured baseline characteristics. RESULTS: The study included 7774 cardiac surgery patients (3963 CABG; 2363 valve replacement/repair; 160 aortic procedures; 1288 multiple procedures, primarily CABG+valve). Mean LOS was 10.7d, including a mean of 4.2d in critical care. Incidences of in-hospital bleeding complications and reoperation for bleeding were 6.7 and 0.3%, respectively. Patients with bleeding had longer LOS (MID: 3.1d; p < 0.0001) and spent more days in critical care (MID: 2.4d; p < 0.0001). Reoperation for bleeding was associated with larger increases in LOS (MID = 4.0d; p = 0.002) and days in critical care (MID = 3.2d; p = 0.001). CONCLUSIONS: Among English cardiac surgery patients, in-hospital bleeding complications were associated with substantial increases in healthcare utilization. Increased use of evidence-based strategies to prevent and manage bleeding may reduce the clinical and economic burden associated with bleeding complications in cardiac surgery.

Using flowable gelatin in anterior cervical spine surgery in real-world practice: a retrospective cohort study.

AIM: To assess the clinical and economic impact of flowable gelatin hemostatic matrix (FGHM) in anterior cervical spine surgery (ACSS). PATIENTS & METHODS: A total of 451 patients with performed ACSS were included to compare FGHM with conventional hemostatic methods for clinical and cost outcomes using propensity score matching method. RESULTS: The comparisons of the matched 125 pairs observed that FGHM was associated with significantly lower blood transfusion volume (11.2 vs 36.3 ml; p = 0.039), shorter postsurgery hospital stay length (3.7 vs 4.7 days; p = 0.002), shorter operation time (103.5 vs 117.7 min; p = 0.004), lower drainage placement rate (51.2 vs 89.6%; p < 0.001) and also lower total hospital costs (median ¥64,717 vs ¥65,064; p = 0.035). CONCLUSION: Use of FGHM in ACSS improved perioperative outcomes without increasing hospital costs.

Burden of air leak complications in thoracic surgery estimated using a national hospital billing database.

BACKGROUND: One of the most common outcomes of lung resections are parenchymal air leaks. These air leaks are most often self-limited and spontaneously resolve several days after surgery. Historically, only prolonged air leaks have been considered to have a significant effect on patient outcomes. This study aims to evaluate the impact of any air leak complications (aALCs) on resource utilization and mortality. METHODS: The Premier Perspective® database was used to identify all elective primary lobectomy, segmentectomy, and wedge resections performed from 2012 to 2014; aALC was defined as a composite of air leak and pneumothorax. Generalized estimating equation models were used to estimate the impact of aALCs on length of stay (LOS), operating room time (ORT), hospital costs, and mortality during index hospitalization. RESULTS: A total of 21,150 patients undergoing lung resection surgery were included in the analysis: lobectomy (n=10,946), segmentectomy (n=1,788), and wedge resection (n=8,416). The overall incidence of aALCs was 24.26% (95% CI [23.68, 24.83]). Identified risk factors included resection type, surgical approach, male gender, and presence of COPD. Patients with aALCs had a significantly higher economic burden (adjusted mean [standard error of mean, SE]: LOS=7.24 [SE=0.12] days; ORT=214.9 [SE=6.4] min; and hospital costs=$26,070 [SE=$1404]) compared to those without aALCs (adjusted mean [SE]: LOS=4.75 [SE=0.07] days; ORT=201.7 [SE=3.9] min; and hospital costs=$19,558 [SE=$399]). aALC was also associated with increased overall index hospitalization mortality (odds ratio=1.90, 95% CI [1.42, 2.55]). CONCLUSION: This analysis showed that aALCs are not only frequent but also associated with significantly higher resource utilization and mortality.

Bleeding-Related Complications and Readmission Rates Associated With Fibrin Sealant Use in Patients Undergoing Coronary Artery Bypass Graft Surgery in the United States.

OBJECTIVES: To compare the clinical and economic outcomes of EVICEL (Ethicon, Inc., Somerville, NJ) and TISSEEL (Baxter Healthcare Corporation, Westlake Village, CA) use in patients undergoing primary coronary artery bypass graft (CABG) surgery. DESIGN: Retrospective database analysis. SETTING: Premier prospective hospital database (June 2009 through March 2014) covering approximately 20% of hospital discharges in the United States. PARTICIPANTS: Adults undergoing primary CABG surgery who received either EVICEL or TISSEEL on the day of surgery (index date). INTERVENTIONS: Two intervention groups were formed, EVICEL and TISSEEL. Clinical outcomes compared included postoperative bleeding complications (International Classification of Diseases, Ninth Revision, Clinical Modification code: 998.1) and number of blood transfusions received on the index day. Economic outcomes compared included hospital length of stay, hospital costs, and 30-day readmission rates. Propensity-score matching was used to control for patient and hospital characteristics. MEASUREMENTS AND MAIN RESULTS: A total of 129,014 primary CABG surgery patients were identified; 986 patients (mean age: 64 years, 73% male) received EVICEL and 6,340 patients (mean age: 65 years, 75% male) received TISSEEL on the index day. After propensity-score matching, patients who received EVICEL compared with TISSEEL had significantly fewer postoperative bleeding complications (3.0% v 5.0%, p = 0.0197), index-day blood transfusion rates (19% v 34%, p<0.0001), readmission rates (18% v 32%, p<0.0001), and costs ($40,736 [standard deviation $19,465] v $46,005 [standard deviation $24,049], p<0.0001). Results from a sensitivity analysis using a generalized linear model to control for other hemostatic agent use also favored EVICEL over TISSEEL. CONCLUSION: Results from this real-world retrospective database analysis showed fewer bleeding complications and lower costs in patients undergoing primary CABG surgery who received EVICEL compared with TISSEEL.