Kalish Jeffrey A, Farber Alik, Homa Karen, Trinidad Magdiel, Beck Adam, Davies Mark G, Kraiss Larry W, Cronenwett Jack L
Boston Medical Center, Boston, Mass.
Boston Medical Center, Boston, Mass.
J Vasc Surg. 2014 Nov;60(5):1238-1246. doi: 10.1016/j.jvs.2014.05.012. Epub 2014 Jun 20.
Surgical site infection (SSI) is a major source of morbidity after infrainguinal lower extremity bypass (LEB). This study examines processes of care associated with in-hospital SSI after LEB and identifies factors that could potentially be modified to improve outcomes.
The Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry (2003 to 2012) was queried to identify in-hospital SSI after 7908 consecutive LEB procedures performed by 365 surgeons at 91 academic and community hospitals in 45 states. Variables associated with SSI were identified using multivariable logistic regression and hierarchical clustering. Expected and observed SSI rates were calculated for each hospital.
The overall in-hospital SSI rate after LEB was 4.8%. Univariate analysis showed that obesity, dialysis, tissue loss, preoperative ankle-brachial index <0.35, distal target, vein graft conduit, continuous incision for vein harvest, transfusion >2 units of packed red blood cells, procedure time >220 minutes, and estimated blood loss >100 mL were associated with higher SSI rates, whereas chlorhexidine (compared with iodine) skin preparation was protective. Multivariable analysis showed independent predictors of SSI included ankle-brachial index <0.35 (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.03-2.30, P < .04), transfusion >2 units (OR, 3.30; 95% CI, 2.17-5.02; P < .001), and procedure time >220 minutes (OR, 2.11; 95% CI, 1.05-4.23; P < .04). Chlorhexidine was protective against SSI (OR, 0.53; 95% CI, 0.35-0.79; P = .002). Stratified analyses based on the presence of tissue loss yielded similar results. Across VQI hospitals, observed SSI rates ranged from 0% to 30%, whereas expected SSI rates adjusted by the four independent predictors ranged from 0% to 7.2%.
In-hospital SSI after LEB varies substantially across VQI hospitals. Three modifiable processes of care (transfusion rate, procedure time, and type of skin preparation) were identified and may be used by hospitals to reduce SSI rates. This study demonstrates the value of the SVS VQI detailed shared clinical registry to identify improvement opportunities directly pertinent to providers that are not available in typical administrative data sets.
手术部位感染（SSI）是腹股沟下下肢旁路移植术（LEB）后发病的主要原因。本研究探讨了与LEB术后医院内SSI相关的护理过程，并确定了可能进行调整以改善结局的因素。
查询血管外科学会（SVS）血管质量改进计划（VQI）登记处（2003年至2012年）的数据，以确定45个州91家学术和社区医院的365名外科医生连续进行的7908例LEB手术后的医院内SSI情况。使用多变量逻辑回归和分层聚类确定与SSI相关的变量。计算每家医院的预期和观察到的SSI发生率。
LEB术后医院内总体SSI发生率为4.8%。单变量分析显示，肥胖、透析、组织缺失、术前踝臂指数<0.35、远端靶点、静脉移植物管道、连续切取静脉、输注超过2单位浓缩红细胞、手术时间>220分钟以及估计失血量>100 mL与较高的SSI发生率相关，而使用氯己定（与碘相比）进行皮肤准备具有保护作用。多变量分析显示，SSI的独立预测因素包括踝臂指数<0.35（比值比[OR]，1.53；95%置信区间[CI]，1.03 - 2.30，P <.04）、输注超过2单位（OR，3.30；95% CI，2.17 - 5.02；P <.001）以及手术时间>220分钟（OR，2.11；95% CI，1.05 - 4.23；P <.04）。氯己定可预防SSI（OR，0.53；95% CI，0.35 - 0.79；P =.002）。基于组织缺失情况的分层分析得出了类似结果。在VQI各医院中，观察到的SSI发生率范围为0%至30%，而经四个独立预测因素调整后的预期SSI发生率范围为0%至7.2%。
LEB术后医院内SSI在VQI各医院之间差异很大。确定了三个可调整的护理过程（输血率、手术时间和皮肤准备类型），医院可利用这些来降低SSI发生率。本研究证明了SVS VQI详细共享临床登记处对于识别与医疗服务提供者直接相关的改进机会的价值，而这些机会在典型的行政数据集中是无法获得的。
