Ann Thorac Surg 2015;99:2061–9
Appendix: The Society of Thoracic Surgeons Infection Definitions
Must have one of the following conditions: a. Wound opened with excision of tissue. b. Positive culture. c. Treatment with antibiotics beyond perioperative prophylaxis. 3. Leg harvest: infection involving a conduit harvest or cannulation site.
2069
Must have one of the following conditions: a. Wound opened with excision of tissue. b. Positive culture. c. Treatment with antibiotics beyond perioperative prophylaxis. 4. Septicemia: positive blood culture from recognized pathogen cultured from one or more cultures. 5. Urinary tract infection: positive urine culture from recognized pathogen cultured from one or more cultures. 6. Pneumonia: positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia. From Definitions of Terms of The Society of Thoracic Surgeons National Cardiac Database. Chicago, IL: The Society of Thoracic Surgeons, 1999:25.
INVITED COMMENTARY This report by Mocanu and associates [1] details an increasing rate of hospital-acquired infections (HAIs) over a 17-year span following cardiac operations in a single institutional experience. The 2.5-fold increase in HAIs over this time comprised deep and superficial surgical site infections, pneumonia, and urinary tract infections. The authors have chosen greater than 9 days to define prolonged postoperative hospitalization and, using conventional statistical methods, have clearly identified HAIs with dramatic odds ratios in association with excessive hospitalization. Their most important observation is the significant increase over this time span in emergency operations, complex procedures with valves and coronary artery bypass being performed simultaneously, and cardiac operations in patients with preoperative days of hospitalization before operation. These important variables combined with the usual risk factors (diabetes, chronic renal failure, increased body mass index) mean that the patient undergoing a cardiac operation in the year 2015 is a far more vulnerable host than the patient of 20 years ago. It is not surprising that HAIs have increased. Continuous quality improvement (CQI) efforts require that the results of care, as identified in this presentation, need to be provided to the surgeon at consistent time periods so that trends in outcomes are understood. Objective outcomes of care (HAI rates or prolonged postoperative length of stay) are necessary for comparison over time, not rates of compliance with CQI process measures. Outcomes feedback to the clinician allows processes of care to be modified for specifically identified problems. For example, prolonged preoperative hospitalization or preoperative days of antibiotic therapy (or both) means that conventional preventive antibiotic
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
choices at the time of operation have to be modified regardless of mandates by the Surgical Care Improvement Project. The patient who is colonized with hospital microflora is not going to get the best result from the traditional cephalosporin antibiotic. In addition, increased pneumonia rates require a reappraisal of endotracheal tube management. Increased catheter-associated urinary tract infections mean a reevaluation of catheter management. Unless the trends of HAIs over time are provided for clinicians to assess the effectiveness of current practice, then true CQI will fail, especially with the immunologically fragile patient of today. The methods of tracking infection and the assessment of risk used by Mocanu and associates are excellent. What remains is a continuous feedback loop to the cardiac surgeon and the surgical team. This continuous feedback will facilitate the redesign of specific patient treatment as the results of care are periodically evaluated. Donald E. Fry, MD, FACS Department of Surgery Northwestern University Michael Pine and Associates 1 East Wacker Dr, #1210 Chicago, IL 60601 e-mail: [email protected]
Reference 1. Mocanu V, Buth KJ, Johnston LB, Davis I, Hirsch GM, Legar e J-F. The importance of continued quality improvement efforts in monitoring hospital-acquired infection rates: a cardiac surgery experience. Ann Thorac Surg 2015;99:2061–9.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.010
ADULT CARDIAC
1. Superficial surgical site infection: superficial sternal wound infection occurring within 30 days of the procedure. 2. Deep surgical site infection: deep sternal wound infection involving muscle, bone, and/or mediastinum.
MOCANU ET AL CQI EFFORTS AND HAI RATES IN CARDIAC SURGERY
Appendix: The Society of Thoracic Surgeons Infection Definitions
Must have one of the following conditions: a. Wound opened with excision of tissue. b. Positive culture. c. Treatment with antibiotics beyond perioperative prophylaxis. 3. Leg harvest: infection involving a conduit harvest or cannulation site.
2069
Must have one of the following conditions: a. Wound opened with excision of tissue. b. Positive culture. c. Treatment with antibiotics beyond perioperative prophylaxis. 4. Septicemia: positive blood culture from recognized pathogen cultured from one or more cultures. 5. Urinary tract infection: positive urine culture from recognized pathogen cultured from one or more cultures. 6. Pneumonia: positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia. From Definitions of Terms of The Society of Thoracic Surgeons National Cardiac Database. Chicago, IL: The Society of Thoracic Surgeons, 1999:25.
INVITED COMMENTARY This report by Mocanu and associates [1] details an increasing rate of hospital-acquired infections (HAIs) over a 17-year span following cardiac operations in a single institutional experience. The 2.5-fold increase in HAIs over this time comprised deep and superficial surgical site infections, pneumonia, and urinary tract infections. The authors have chosen greater than 9 days to define prolonged postoperative hospitalization and, using conventional statistical methods, have clearly identified HAIs with dramatic odds ratios in association with excessive hospitalization. Their most important observation is the significant increase over this time span in emergency operations, complex procedures with valves and coronary artery bypass being performed simultaneously, and cardiac operations in patients with preoperative days of hospitalization before operation. These important variables combined with the usual risk factors (diabetes, chronic renal failure, increased body mass index) mean that the patient undergoing a cardiac operation in the year 2015 is a far more vulnerable host than the patient of 20 years ago. It is not surprising that HAIs have increased. Continuous quality improvement (CQI) efforts require that the results of care, as identified in this presentation, need to be provided to the surgeon at consistent time periods so that trends in outcomes are understood. Objective outcomes of care (HAI rates or prolonged postoperative length of stay) are necessary for comparison over time, not rates of compliance with CQI process measures. Outcomes feedback to the clinician allows processes of care to be modified for specifically identified problems. For example, prolonged preoperative hospitalization or preoperative days of antibiotic therapy (or both) means that conventional preventive antibiotic
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
choices at the time of operation have to be modified regardless of mandates by the Surgical Care Improvement Project. The patient who is colonized with hospital microflora is not going to get the best result from the traditional cephalosporin antibiotic. In addition, increased pneumonia rates require a reappraisal of endotracheal tube management. Increased catheter-associated urinary tract infections mean a reevaluation of catheter management. Unless the trends of HAIs over time are provided for clinicians to assess the effectiveness of current practice, then true CQI will fail, especially with the immunologically fragile patient of today. The methods of tracking infection and the assessment of risk used by Mocanu and associates are excellent. What remains is a continuous feedback loop to the cardiac surgeon and the surgical team. This continuous feedback will facilitate the redesign of specific patient treatment as the results of care are periodically evaluated. Donald E. Fry, MD, FACS Department of Surgery Northwestern University Michael Pine and Associates 1 East Wacker Dr, #1210 Chicago, IL 60601 e-mail: [email protected]
Reference 1. Mocanu V, Buth KJ, Johnston LB, Davis I, Hirsch GM, Legar e J-F. The importance of continued quality improvement efforts in monitoring hospital-acquired infection rates: a cardiac surgery experience. Ann Thorac Surg 2015;99:2061–9.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.010
ADULT CARDIAC
1. Superficial surgical site infection: superficial sternal wound infection occurring within 30 days of the procedure. 2. Deep surgical site infection: deep sternal wound infection involving muscle, bone, and/or mediastinum.
MOCANU ET AL CQI EFFORTS AND HAI RATES IN CARDIAC SURGERY
