The Challenge of Postoperative Infections and a Possible Solution
Does following the NSQIP reduce post-operative UTIs?
Hospitalization, regardless of the reason, always comes with the inherent risk of health care-associated infections (HAIs). Indeed, the Centers for Disease Control and Prevention (CDC) estimates that roughly 721,800 HAIs occur every year in the United States. Some of the most common infections are pneumonia, surgical site infections (SSIs), and urinary tract infections (UTIs). Of all the UTIs that occur due to hospitalization, 75% are related to catheter use, as 15% to 25% of patients receive urinary catheters during their hospital stay. A quality improvement plan such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) may help to change that or at least, identify which procedures need more attention.
A recent study looked at procedure-specific trends in post-operative complications for 10 surgical operations. The 10 procedures (colectomy, esophagectomy, hepatectomy, hysterectomy, pancreatectomy, proctectomy, total hip arthroplasty, total knee arthroplasty, thyroidectomy, and ventral hernia repair) were tracked through data reported into the ACS NSQIP from 2008 to 2015. According to the authors, “trends in risk-adjusted, standardized, smoothed rates were constructed for each procedure across 6 outcomes (mortality, pneumonia, renal failure, SSI, unplanned intubation, and UTI).” The investigators then implemented the NSQIP, which is aimed to help reduce complications by giving them more attention and linking their incidence (or absence of) with Medicare payments, to determine if it would help to decrease the incidence of these outcomes.
The investigators reviewed over 1.25 million cases of these 10 procedures and found that “overall unadjusted rate for mortality across all 10 procedures was 1.08%, for pneumonia 1.44%, for renal failure 0.67%, for surgical site infection 5.28%, for unplanned intubation 1.11%, and for UTI 1.86%.” Within these hospitals that followed NSQIP, hepatectomy showed the greatest improvement and of the post-operative complications, UTIs were the most improved across 8 of the surgeries. (Interestingly, SSIs were only tracked for 1 month postoperatively, which is shorter than the CDC criteria for surveillance of surgeries like knee and hip prosthesis, which is 90 days.)
Overall, the investigators found that after implementing the NSQIP, improvement was seen in the post-operative complications, but such changes varied across operation and outcome.
Although the quality measures of NSQIP helped to reduce HAIs and adverse postoperative complications, there is still much work to be done. In fact, the investigators found that the SSI rates for pancreatectomies increased during the studied time. A reduction in UTIs is a wholly important step in the right direction as they are common and such infections result in the use of antibiotics and tend to mean a longer stay for patients, which then increases their risk for another HAI. The CDC criteria for catheter-associated urinary tract infections (CAUTIs) is catheterization for 2 or more days; however, even short-term use can result in infections. For patients who are in intensive care or hospitalized for surgery, the use of catheters is more likely, which then puts them at a greater risk. Even if a catheter is utilized for a short period of time, patients can still contract a CAUTI.
Quality improvement efforts are showing progress, but it is important that we continue to address the sources of adverse patient outcomes and how we can best reduce them.