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Readmission from orthopedic surgical site infections: an integrative review

Reingreso por infección del sitio quirúrgico ortopédico: una revisión integradora

Abstract

OBJECTIVE

Characterizing readmissions from orthopedic surgical site infections.

METHOD

An integrative review of literature in the LILACS, IBECS, MEDLINE, Cochrane, SciELO and PUBMED databases, using the descriptors Patient readmission, Wound infection, Cross infection, Orthopedic procedures, Orthopedics.

RESULTS

78 studies were identified and 10 publications were selected. Surgical site infections are the most common cause of unplanned orthopedic readmissions, representing long periods of hospitalization, new surgical procedures and high costs, and greater possibility of subsequent hospitalizations. Most significant predictors have indicated average length of hospitalization, need for intensive care, emergency status at admission, risk of death, age > 65 years, males and higher body mass index.

CONCLUSION

Readmission rates have increasingly become measures of quality and concerns about costs. New studies could involve issues related to indirect costs, specifically social and psychological costs.

Descriptors
Patient Readmission; Surgical Wound Infection; Cross Infection; Orthopedics Procedures; Orthopedics Nursing; Review

Resumen

OBJETIVO

Caracterizar los reingresos por infección del sitio quirúrgico ortopédico.

MÉTODO

Revisión integradora de la literatura, en las bases de datos LILACS, IBECS, MEDLINE, Cochrane, SciELO y PUBMED, por medio de los descriptores Reingreso del paciente, Infección de la herida operatoria, Infección hospitalaria, Procedimientos ortopédicos, Ortopedia.

RESULTADOS

Fueron identificados 78 estudios y seleccionadas 10 publicaciones. La infección del sitio quirúrgico es la causa más frecuente entre los reingresos ortopédicos no planificados, que representan largas estancias hospitalarias, nuevas intervenciones quirúrgicas y costos elevados, además de mayor posibilidad de ingresos subsiguientes. Los factores predictivos más significativos señalaron tiempo de estancia media, necesidad de cuidados intensivos, status de urgencia en el ingreso, riesgo de muerte, edad > 65 años, sexo masculino y mayor índice de masa corpórea.

CONCLUSIÓN

Las tasas de reingreso se hacen cada vez más medidas de cualidad y preocupación con relación a los costos. Nuevos estudios podrían involucrar cuestiones relacionadas con costos indirectos, especialmente los sociales y psicológicos.

Descriptores
Readmisión del Paciente; Infección de Herida Operatoria; Infección Hospitalaria; Procedimientos Ortopédicos; Enfermería Ortopédica; Revisión

Resumo

OBJETIVO

Caracterizar as readmissões por infecção do sítio cirúrgico ortopédico.

MÉTODO

Revisão integrativa da literatura, nas bases de dados LILACS, IBECS, MEDLINE, Cochrane, SciELO e PUBMED, por meio dos descritores Readmissão do paciente, Infecção da ferida operatória, Infecção hospitalar, Procedimentos ortopédicos, Ortopedia.

RESULTADOS

Identificados 78 estudos e selecionadas 10 publicações. A infecção do sítio cirúrgico é a causa mais frequente entre as readmissões ortopédicas não planejadas, que representam longos períodos de internação, novas intervenções cirúrgicas e custos elevados, além de maior possibilidade de internações subsequentes. Fatores preditivos mais significantes apontaram tempo médio de internação, necessidade de cuidados intensivos,status de urgência na admissão, risco de morte, idade > 65 anos, sexo masculino e maior índice de massa corporal.

CONCLUSÃO

Taxas de readmissão tornam-se cada vez mais medidas de qualidade e preocupação em relação a custos. Novos estudos poderiam envolver questões relacionadas a custos indiretos, especificamente os sociais e psicológicos.

Descritores
Readmissão do Paciente; Infecção da Ferida Operatória; Infecção Hospitalar; Procedimentos Ortopédicos; Enfermagem Ortopédica; Revisão

Introduction

Surgical site infections (SSI) are those resulting from invasive surgical procedures with important aspects related to quality in the provision of health care(11 Morgan A, Khan A, Amin T. Challenges in evaluating all-cause hospital readmission measures for use as national consensus standards. Perm J. 2013;17(4):14-8.

2 Sellers MM, Merkow RP, Halverson A, Hinami K, Kelz RR, Bentren DJ et al. Validation of new readmission data in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2013;216(3):420-7.
-33 Rosen AK, Chen Q, Shin MH, O'Brien W, Shwartz M, Mull HJ, et al. Medical and surgical readmissions in the Veterans Health Administration: what proportion are related to the index hospitalization? Med Care. 2014;52(3):243-9.) . Prevention and control of this condition constitutes fundamental steps for safety and improvement of health services (44 Dias-Agero-Pérez C, Pita-López MJ, Robustillo-Rodela A, Figuerola-Tejerina A, Monge-Jodrá V, Grupo de Trabajo INCLIMEDCC de La Comunidad de Madrid. Assessment of the surgical site infection in 14 hospitals of the Madrid Region: an incidence study. Enferm Infecc Microbiol Clin. 2011;29(4):257-62.) . The identification of risk factors related to patients and procedures is essential and should direct strategies to prevent this complication (55 Ovaska MT, Mäkinen TJ, Madanat R, Huotari K, Vahlberg T, Hirvensalo E et al. Risk Factors for deep surgical site infection following operative treatment of ankle fractures. J Bone Joint Surg Am. 2013;95(4):348-53.) . There is also the possibility of validating a new surgical site infection risk nursing diagnosis with the North American Diagnosis Association (NANDA), that may positively impact clinical practice (66 Ercole FF, Chianca TC, Duarte D, Starling CE, Carneiro M. Surgical Site Infection in patients submitted to orthopedic surgery: the NNIS Risk Index and Risk Prediction. Rev Lat Am Enfermagem. 2011;19(6):1362-8.) .

Due to the growing concern on the subject, the Centre for Diseases Control and Prevention (CDC) published a study in 2011 on the prevalence of health care associated infections in acute care hospitals in the United States, with results indicating that approximately one in every 25 hospitalized patients have at least one infection associated to health care, especially pneumonia and SSI (77 Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198-208.) .

SSI are associated with increased morbidity and mortality (88 Schweizer ML, Cullen JJ, Perencevich EN, Vaughan Sarrazin MS. Costs associated with surgical site infections in Veterans Affairs Hospital. JAMA. Surg. 2014;149(6):575-81.) , they contribute to the need of new surgical procedures, increased hospital stay and use of antimicrobials, which means harm to patients and increased hospital costs (99 Harrop JS, Styliaras JC, Ooi YC, Radcliff KE, Vaccaro AR, Wu C. Contributing factors to surgical site infections. J Am Acad Orthop Surg. 2012;20(2):94-101.-1010 Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-85.) .

In the orthopedic specialization, surgical site infections can compromise the proposed initial treatment (1111 Romanò CL, Toscano M, Romanò D, Drago L. Antibiofilm agents and implant-related infections in orthopaedics: Where we are? J Chemother. 2013;25(2):67-80.) , considering aggressive debridement, late and polymicrobial infections, removal of implants, replantation and arthrodesis, in an attempt to avoid treatment failure(1212 Maruo K, Berven SH. Outcome and treatment of postoperative spine surgical site infections: predictors of treatment success and failure. J Orthop Sci. 2014;19(3):398-404.) .

This condition is relevant taking into consideration projections on the volume of certain orthopedic procedures, for example, by 2030 in the United States, a significant increase is expected in the number of primary hip (174%) and knee (673%) arthroplasties and their reviews (in total, 601%). These are numbers that could support political decisions related to training of specialized personnel, targeting resources and quality of care (1313 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.. J Bone Joint Surg Am 2007;89(4):780-5.).

Post-operative infections in orthopedics are considered serious and devastating complications which generate economic, clinical and social impacts (1414 Campoccia D, Montanaro L, Arciola CR. A review of the clinical implications of anti-infective biomaterials and infection-resistant surfaces. Biomaterials. 2013;34(33):8018-29.) , leading to subsequent hospitalizations and new surgical interventions. The whole multidisciplinary team should be involved in order to recognize conditions and risk factors already identified in the literature in advance. Nurses assume a strategic role for closely monitoring infections related to health care and for leading the establishment of preventive measures aimed at patient safety (66 Ercole FF, Chianca TC, Duarte D, Starling CE, Carneiro M. Surgical Site Infection in patients submitted to orthopedic surgery: the NNIS Risk Index and Risk Prediction. Rev Lat Am Enfermagem. 2011;19(6):1362-8.) .

Hospital readmissions have increasingly gotten the world's attention as a measure of quality, and one of the most important points in reducing associated costs(11 Morgan A, Khan A, Amin T. Challenges in evaluating all-cause hospital readmission measures for use as national consensus standards. Perm J. 2013;17(4):14-8.,33 Rosen AK, Chen Q, Shin MH, O'Brien W, Shwartz M, Mull HJ, et al. Medical and surgical readmissions in the Veterans Health Administration: what proportion are related to the index hospitalization? Med Care. 2014;52(3):243-9.) . According to WHO, when readmissions occur after specific hospital procedures, it is considered an undesirable result, and it must function as a starting point for analyzing care processes (1515 World Health Organization; Regional Office for Europe. Do current discharge arrangements from inpatient hospital care for the elderly reduce readmission rates, the length of inpatient stay or mortality, or improve health status? [Internet]. Geneva; 2005 [cited 2015 May 16]. Available from: http://www.euro.who.int/__data/assets/pdf_ file/0006/74670/E87542.pdf?ua=1
http://www.euro.who.int/__data/assets/pd...
) . However, the data collected must be consistent enough for a more accurate analysis of planned and unplanned readmissions and to signify advantages in direct actions (22 Sellers MM, Merkow RP, Halverson A, Hinami K, Kelz RR, Bentren DJ et al. Validation of new readmission data in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2013;216(3):420-7.) . In recent years, efforts have arisen to reduce readmission rates because of the growing increase in reported numbers as well as the financial implications that have been imposed on lenders (1010 Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-85.) .

Scientific publications normally show unplanned readmission for orthopedic surgery patients through studies that analyze causes, the number of additional hospitalization days, predominant microorganisms and associated costs (66 Ercole FF, Chianca TC, Duarte D, Starling CE, Carneiro M. Surgical Site Infection in patients submitted to orthopedic surgery: the NNIS Risk Index and Risk Prediction. Rev Lat Am Enfermagem. 2011;19(6):1362-8.,88 Schweizer ML, Cullen JJ, Perencevich EN, Vaughan Sarrazin MS. Costs associated with surgical site infections in Veterans Affairs Hospital. JAMA. Surg. 2014;149(6):575-81.,1616 Dubory A, Giorgi H, Walter A, Bouyer B, Vassal M, Dhenin A, et al. Surgical-site infection in spinal injury: incidence and risk factors in a prospective cohort of 518 patients. Eur Spine J. 2015;24(3):543-54.-1717 Rasouli MR, Respreto C, Maltenfort MG, Purtill JJ, Parvizi J. Risk factors for surgical site infection following total joint arthroplasty. J Bone Joint Surg Am 2014;96(18):e158.) . As research is presented and tends to reflect the quality of the first treatment, it needs to analyze the complexity of factors related to readmission in order to fill this gap of knowledge (33 Rosen AK, Chen Q, Shin MH, O'Brien W, Shwartz M, Mull HJ, et al. Medical and surgical readmissions in the Veterans Health Administration: what proportion are related to the index hospitalization? Med Care. 2014;52(3):243-9.) . In addition, reinstatement is not desired by patients (1010 Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-85.) .

Therefore, it is relevant to suggest an expansion on the focus of the approach, gathering and synthesizing of information to answer what characteristics are available in the literature on readmissions from orthopedic surgical site infections.

As a result, this integrative review aims to characterize readmissions from orthopedic surgical site infections in the last five years.

Method

Integrative literature review enables searching/finding/discovering the state of the art of a particular theme which has been presented empirically or theoretically. In this way, it becomes possible to identify trends or evidence underlying the proposed study. The steps for conducting it include six phases: preparation of the research question; search and definition of the sample through the selected descriptors; data collection; results analysis; discussion; and disclosure (1818 Teixeira E, Medeiros HP, Nascimento MHM, Costa e Silva BA, Rodrigues C. Integrative literature review step-by-step & convergences with other methods of review. Rev Enferm UFPI. 2013;2 Suppl esp:3-7.) .

For this integrative literature review, the identified descriptors from Medical Subject Headings (MeSH) were used, through the website http://www.nlm.nih.gov/mesh/MBrowser.html , which also coincided with Health Sciences descriptors of the Virtual Health Library (VHL): "patient readmission," "surgical wound infection," "cross infection," "orthopedics," "orthopedics procedures." The search for publications took place in December 2014 in the VHL Portal, through the site www.bvsalud.org, which includes the bibliographic index of Latin American and Caribbean Health Sciences (LILACS), Bibliographic Index on Health Sciences from Spain (IBECS), International Database for Medical Literature (MEDLINE), Cochrane Library and Scientific Electronic Library Online (SciELO).

The Boolean term "AND" was used for the following descriptor crossings: patient readmission AND surgical wound infection AND orthopedics; patient readmission AND surgical wound infection AND orthopedics procedures; patient readmission AND cross infection AND orthopedics; patient readmission AND cross infection AND orthopedics procedures; patient readmission AND orthopedics; and patient readmission AND orthopedics procedures.

Articles that addressed issues related to readmission from orthopedic surgical site infections published in Portuguese, English, Spanish, Italian and French during the past five years (2010-2014) were included. The period was defined in order to make it possible to condense the latest information on the formulated question. Publications without abstracts were excluded, along with those that did not meet inclusion criteria regarding language and defined year of publication, or those which did not address the proposed topic.

To assess the methodological quality of the studies, tools from Joanna Briggs Institute were used, which are JBI Critical Appraisal Checklist for Comparable Cohort/Case control, and JBI Critical Appraisal Checklist for Descriptive/Case Series (1919 The Joanna Briggs Institute. Joanna Briggs Institute reviewers' manual 2014 edition [Internet]. Adelaide: JBI; 2014 [cited 2015 May 15]. Available from: Available from: http://www.joannabriggs.org/assets/docs/sumari/ReviewersManual-2014.pdf
http://www.joannabriggs.org/assets/docs/...
).

Results

From crossing the descriptors in the selected research databases 78 queries meeting inclusion criteria were identified. Of these, 19 publications were read in full and nine were excluded for not presenting specific data on readmissions from orthopedic surgical site infections; they only included the infections in the general data of the institutions that served as the stage for the various studies.

Figure 1 shows the diagram of the inclusion and exclusion process of studies by crossing the descriptors.

Figure 1
Diagram of the inclusion and exclusion process of studies in the review.

The search in the databases resulted in a sample of 10 scientific articles. Data were descriptively analyzed and synthesized in order to reach the objective. For this purpose, a form was used to collect information on the variables related to the characteristics of publications (publication year, journal, study objectives, research design) and on the variable of interest (aspects related to readmissions from orthopedic surgery site infections: incidence, predictors, more significant comorbidities, length of hospital stay).

Most of the research was published in 2013 (60%) and 2014 (20%). The studies had a total of 60 authors, averaging six per publication, one of which had 10 authors. Regarding the journals where the papers were published, more than half were related to the specialization of orthopedics (70%), and retrospective cross-sectional descriptive design was the most used (80%). All of the studies (100%) were in English and most of the investigations were conducted in American hospitals (60%), two in New York, two in Pennsylvania, one in California and one in Washington. Four studies had no reference to the location where the research was conducted (Chart 1).

Chart 1
Characterization of the analyzed publications - Coimbra, Portugal, 2014

Discussion

In analyzing the variable of interest of this review, meaning the readmission characteristics from orthopedic surgical site infection, it was found that the objectives of included publications varied between characterizing unplanned readmissions within 30 days after discharge (2020 McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine (Phila Pa 1986). 2012;37(14):1260-6.

21 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.

22 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.
-2323 Nacke E, Ramos N, Stein S, Hutzler L, Bosco JA 3rd. When do readmissions for infection occur after spine and total joint procedures? Clin Orthop Relat Res. 2013;471(2):569-73.) , identifying predictors of surgical readmission within 30 days in overall readmission rates(2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.) , assessing their impact on costs, average stay and overall readmission rates, as well as its causes and risk factors (2020 McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine (Phila Pa 1986). 2012;37(14):1260-6.-2121 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.,2525 Zmistowski B, Respreto C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors.. J Bone Joint Surg Am 2013;95(20):1869-76.-2626 Kapadia BH, McElroy MJ, Issa K, Johnson AJ, Bozic KJ, Mont MA. The economic impact of periprosthetic infections following total knee arthroplasty. J Arthroplasty. 2014;29(5):929-32.) and associated comorbidities (2727 Walid MS, Robinson JS 3rd, Robinson ER, Brannick BB, Ajjan M, Robinson JS Jr. Comparison of outpatient and inpatient spine surgery patients with regards to obesity, comorbidities and readmission for infection. J Clin Neurosci. 2010;17(12):1497-8.) . Studies analyzing the impact of seasonality (2828 Kane P, Chen C, Post Z, Radcliff K, Orozco F, Ong A. Sazonality of infection rates after total joint arthroplasty. Orthopedics. 2014;37(2):182-6.) and influence of goals and educational video programs on events that also included readmission (2929 Wang W, Dudjak LA, Larue EM, Ren D, Scholle C, Wolf GA. The influence of goal setting and smart room patient education videos on readmission rate, length of stay, and patient satisfaction in orthopedic spine population. Comput Inform Nurs. 2013;31(9):450-6.) were also performed. There is diversity among generating motives for research, even if the publications have been selected by the inclusion criteria defined in this review.

As for the methodological quality assessed through Joanna Briggs Institute tools, all the articles were approved considering that at least half (50%) of the checklist for each instrument should be answered positive. The JBI Critical Appraisal Checklist for Comparable Cohort/Case control instrument assessed the similarity in the course of their condition or disease from the selection of patients, which for this literature review refers to orthopedic surgical site infection; and sample representativeness of the population as a whole. Also considered were the identification and treatment of potential confounders; sufficient time to follow cases to meet the objectives of the respective studies; and choosing appropriate statistical methods. There was no mention in this sample of one of the aforementioned checklist items, which refers to inclusion in the analysis results of people who withdrew from the study. It is believed that this was due to the fact that most studies are based on registries of medical records and institutional reports. The other instrument, JBI Critical Appraisal Checklist for Descriptive/Case Series, also considered clarity in the definition of the inclusion criteria in addition to the above items, and existing comparisons if there was sufficient description of the groups. The criteria for evaluation of the results should be objective and reliable, to which all the articles met this issue by way of a detailed description of the analysis methodology (1919 The Joanna Briggs Institute. Joanna Briggs Institute reviewers' manual 2014 edition [Internet]. Adelaide: JBI; 2014 [cited 2015 May 15]. Available from: Available from: http://www.joannabriggs.org/assets/docs/sumari/ReviewersManual-2014.pdf
http://www.joannabriggs.org/assets/docs/...
) . The evaluation of the quality of publications including study sites, target, sampling methods, research tools, collection and analysis procedures, among others, are transformed into important points for the readers' evaluation as to the meaning of the study results (3030 Ehlers V, Ethical responsibilities of authors. Int Nur Rev. 2014;61(2):159-61.) .

In the global context of readmissions, there was a predominance in readmissions related to surgical services observed when compared to clinical (2121 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.-2222 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.) . This fact is confirmed by a study that analyzed the unplanned readmissions and compared their causes between medical and surgical discharges, where it found that postoperative complications accounted for 70.5% of readmissions related to surgical discharges (33 Rosen AK, Chen Q, Shin MH, O'Brien W, Shwartz M, Mull HJ, et al. Medical and surgical readmissions in the Veterans Health Administration: what proportion are related to the index hospitalization? Med Care. 2014;52(3):243-9.) . Surgical site infection was also the most common type of infection, with a predominance of those classified as deep (44 Dias-Agero-Pérez C, Pita-López MJ, Robustillo-Rodela A, Figuerola-Tejerina A, Monge-Jodrá V, Grupo de Trabajo INCLIMEDCC de La Comunidad de Madrid. Assessment of the surgical site infection in 14 hospitals of the Madrid Region: an incidence study. Enferm Infecc Microbiol Clin. 2011;29(4):257-62.) ; and events related to the orthopedic site were the main reason for readmissions (2020 McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine (Phila Pa 1986). 2012;37(14):1260-6.

21 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.
-2222 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.,2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.-2525 Zmistowski B, Respreto C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors.. J Bone Joint Surg Am 2013;95(20):1869-76.,2929 Wang W, Dudjak LA, Larue EM, Ren D, Scholle C, Wolf GA. The influence of goal setting and smart room patient education videos on readmission rate, length of stay, and patient satisfaction in orthopedic spine population. Comput Inform Nurs. 2013;31(9):450-6.) , ranging from 32.0 to 40.6% in the group of unplanned readmissions.

Among the statistically significant predictors are: the average length of stay when evaluating all readmissions for orthopedic SSI (2121 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.) ; those new admissions which occurred after arthroplasty in general (2525 Zmistowski B, Respreto C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors.. J Bone Joint Surg Am 2013;95(20):1869-76.) , or just the knee(2626 Kapadia BH, McElroy MJ, Issa K, Johnson AJ, Bozic KJ, Mont MA. The economic impact of periprosthetic infections following total knee arthroplasty. J Arthroplasty. 2014;29(5):929-32.) ; and, more specifically, when the stay is greater than five days in SSI readmission after spinal surgeries (2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.) . The need for intensive care after the first procedure was considered significant when defining risk factors for orthopedic readmission in 30 days for infection(2121 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.) . In spinal surgeries with urgent admission status, the risk of death and age > 65 years were predictive factors for repeated hospitalizations (2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.) . Knee arthroplasty, male gender and higher body mass index (BMI) are also among the predictors of re-hospitalization for unplanned causes, and also includes SSI when the infection is analyzed after arthroplasty in general (2525 Zmistowski B, Respreto C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors.. J Bone Joint Surg Am 2013;95(20):1869-76.) . A multicenter prospective study in the context of spinal injury obtained an incidence rate and identification of risk factors for SSI equivalent to those found in the literature for spinal surgery (1616 Dubory A, Giorgi H, Walter A, Bouyer B, Vassal M, Dhenin A, et al. Surgical-site infection in spinal injury: incidence and risk factors in a prospective cohort of 518 patients. Eur Spine J. 2015;24(3):543-54.) .

In an attempt to correlate between seasonality and risk of infection in total arthroplasties, there was a statistically significant difference between infections that occurred in the summer/fall compared to winter/spring. However, the authors point out limitations, especially with regard to classifying the potential for surgery contamination (2828 Kane P, Chen C, Post Z, Radcliff K, Orozco F, Ong A. Sazonality of infection rates after total joint arthroplasty. Orthopedics. 2014;37(2):182-6.) .

Among the comorbidities, obesity is a possible predictor of readmissions for SSI when analyzing the characteristics of patients operated on an outpatient basis and inpatient management. Although there was no significant difference in readmissions for infection related to the type of service, all readmitted patients had a BMI > 30 (2727 Walid MS, Robinson JS 3rd, Robinson ER, Brannick BB, Ajjan M, Robinson JS Jr. Comparison of outpatient and inpatient spine surgery patients with regards to obesity, comorbidities and readmission for infection. J Clin Neurosci. 2010;17(12):1497-8.) . Diabetes also emerged as a predictor of SSI in research that investigated the incidence and risk factors in the procedures related to spinal vertebrae injury (1616 Dubory A, Giorgi H, Walter A, Bouyer B, Vassal M, Dhenin A, et al. Surgical-site infection in spinal injury: incidence and risk factors in a prospective cohort of 518 patients. Eur Spine J. 2015;24(3):543-54.) .

Readmission rates were significantly more expressive in spinal surgery compared to arthroplasties (2323 Nacke E, Ramos N, Stein S, Hutzler L, Bosco JA 3rd. When do readmissions for infection occur after spine and total joint procedures? Clin Orthop Relat Res. 2013;471(2):569-73.,2929 Wang W, Dudjak LA, Larue EM, Ren D, Scholle C, Wolf GA. The influence of goal setting and smart room patient education videos on readmission rate, length of stay, and patient satisfaction in orthopedic spine population. Comput Inform Nurs. 2013;31(9):450-6.) . In the referred study, two types of surgeries were grouped into very low overall rates of infection in the institution, and therefore of readmissions for this reason (2323 Nacke E, Ramos N, Stein S, Hutzler L, Bosco JA 3rd. When do readmissions for infection occur after spine and total joint procedures? Clin Orthop Relat Res. 2013;471(2):569-73.) . Educational videos and goals in the planning of discharge evaluated the influence on readmission rates for orthopedic SSI, so the study results show the comparison between spinal surgeries and arthroplasties(2929 Wang W, Dudjak LA, Larue EM, Ren D, Scholle C, Wolf GA. The influence of goal setting and smart room patient education videos on readmission rate, length of stay, and patient satisfaction in orthopedic spine population. Comput Inform Nurs. 2013;31(9):450-6.) . With regard to arthroplasties, in order to identify the incidence, causes and risk factors for readmission, the hip resulted in a higher percentage compared to the knee, but without statistical significance, despite similar preoperative characteristics such as age, gender and comorbidities (2323 Nacke E, Ramos N, Stein S, Hutzler L, Bosco JA 3rd. When do readmissions for infection occur after spine and total joint procedures? Clin Orthop Relat Res. 2013;471(2):569-73.) . Also in relation to arthroplasties, SSI was the leading cause of readmission after hip surgery, while knee surgery had a predominance of stiffness in the joint (2525 Zmistowski B, Respreto C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors.. J Bone Joint Surg Am 2013;95(20):1869-76.) . Regarding spinal surgery, more readmissions occurred due to infection after laminectomy for decompression, cervical spine fusion, thoracolumbar with posterior access and lumbar, in relation to the others (2020 McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine (Phila Pa 1986). 2012;37(14):1260-6.) . One study found no significant difference between readmissions by SSI after cervical and lumbar procedures (2323 Nacke E, Ramos N, Stein S, Hutzler L, Bosco JA 3rd. When do readmissions for infection occur after spine and total joint procedures? Clin Orthop Relat Res. 2013;471(2):569-73.) . Regardless, in order to assess whether the preparation for discharge of elderly could reduce readmission rates and hospital stay, the WHO emphasizes that planning is the key to ensuring safe and effective continuity of health care (1515 World Health Organization; Regional Office for Europe. Do current discharge arrangements from inpatient hospital care for the elderly reduce readmission rates, the length of inpatient stay or mortality, or improve health status? [Internet]. Geneva; 2005 [cited 2015 May 16]. Available from: http://www.euro.who.int/__data/assets/pdf_ file/0006/74670/E87542.pdf?ua=1
http://www.euro.who.int/__data/assets/pd...
).

The average length of hospital stay increased by four days in comparing planned and unplanned readmissions, and between unplanned events, those resulting from surgical site infection presented an average of 9.9 days of stay (2222 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.) . In another study that compared a group of patients with postoperative infection and a group who did not develop infection in order to assess the impact of post-arthroplasty knee infections for length of stay, readmissions and associated costs, it was found that the average hospitalization stay among those infected was significantly higher than in the control group, being composed of individuals who were not infected after primary knee arthroplasties. The number of subsequent hospitalizations or readmissions within one year of follow-up was higher in the uninfected group (2626 Kapadia BH, McElroy MJ, Issa K, Johnson AJ, Bozic KJ, Mont MA. The economic impact of periprosthetic infections following total knee arthroplasty. J Arthroplasty. 2014;29(5):929-32.) .

Two publications pointed out the need for further surgery depending on SSI and subsequent readmissions (2020 McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine (Phila Pa 1986). 2012;37(14):1260-6.,2323 Nacke E, Ramos N, Stein S, Hutzler L, Bosco JA 3rd. When do readmissions for infection occur after spine and total joint procedures? Clin Orthop Relat Res. 2013;471(2):569-73.) . Secondary procedures were performed on most SSI patients readmitted after spinal surgeries and arthroplasties(2323 Nacke E, Ramos N, Stein S, Hutzler L, Bosco JA 3rd. When do readmissions for infection occur after spine and total joint procedures? Clin Orthop Relat Res. 2013;471(2):569-73.) . In more than half of the unplanned readmissions the patients returned to surgery, most as a result of postoperative infection, which also comes as second cause of readmission after surgical revisions (2020 McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine (Phila Pa 1986). 2012;37(14):1260-6.) . Research that addresses the factors contributing to the SSI has confirmed that this complication allows for revision surgery, delayed wound healing and increased length of hospital stay (99 Harrop JS, Styliaras JC, Ooi YC, Radcliff KE, Vaccaro AR, Wu C. Contributing factors to surgical site infections. J Am Acad Orthop Surg. 2012;20(2):94-101.) . Another study to identify risk factors associated with treatment failures of SSI after spinal surgery indicates the prevalence of aggressive surgical debridement and prolonged antibiotic use (1212 Maruo K, Berven SH. Outcome and treatment of postoperative spine surgical site infections: predictors of treatment success and failure. J Orthop Sci. 2014;19(3):398-404.).

For analyzing costs it becomes important to properly characterize readmissions as planned and unplanned, considering that the actions or interventions in each group have different focuses. In addition, unplanned occurrences represent higher cost, and at the same time, the greatest potential for improving quality of care(2121 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.-2222 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.,2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.) , constituting an organizational challenge. Researchers that have examined causes of unplanned readmission affirm that interventions that improve the quality of care processes on the first admission tend to be more effective in reducing subsequent events of clinically-related hospitalization (33 Rosen AK, Chen Q, Shin MH, O'Brien W, Shwartz M, Mull HJ, et al. Medical and surgical readmissions in the Veterans Health Administration: what proportion are related to the index hospitalization? Med Care. 2014;52(3):243-9.) . Other studies also consider that there is an increase of infections due to costs (88 Schweizer ML, Cullen JJ, Perencevich EN, Vaughan Sarrazin MS. Costs associated with surgical site infections in Veterans Affairs Hospital. JAMA. Surg. 2014;149(6):575-81.-99 Harrop JS, Styliaras JC, Ooi YC, Radcliff KE, Vaccaro AR, Wu C. Contributing factors to surgical site infections. J Am Acad Orthop Surg. 2012;20(2):94-101.) ; that efforts should be concentrated on patients with higher risk of readmission (1010 Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-85.) ; and that there would be a large annual savings by reducing infection rates related to health care (88 Schweizer ML, Cullen JJ, Perencevich EN, Vaughan Sarrazin MS. Costs associated with surgical site infections in Veterans Affairs Hospital. JAMA. Surg. 2014;149(6):575-81.) . The US Department of Health and Human Services considers that the approach to readmission causes becomes a useful measure for the accountability of health plans in the sense that it assumes the coordination of effective care with institutions and health professionals (11 Morgan A, Khan A, Amin T. Challenges in evaluating all-cause hospital readmission measures for use as national consensus standards. Perm J. 2013;17(4):14-8.) .

Readmission rates when stratified, and those unrelated to the assistance itself are eliminated (such as cancellations or suspension of surgeries), become more accurate for comparison between institutions and may set real readmission event costs(2222 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.,2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.) . Planned readmissions to perform surgical steps, among other reasons, can mean 25% of all readmissions (2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.) . Those decided early should be used as an indicator of surgical care quality (2020 McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine (Phila Pa 1986). 2012;37(14):1260-6.) . In addition, one cannot fail to point out that there is still need for more studies involving surgery with implants, especially with regards to the safety of antibiofilm strategies to treat infections involving bone tissue and biomaterials (1111 Romanò CL, Toscano M, Romanò D, Drago L. Antibiofilm agents and implant-related infections in orthopaedics: Where we are? J Chemother. 2013;25(2):67-80.) . This would also be a point to consider in studies on readmission following orthopedic surgery, considering that infections associated with the use of biomaterials differ in epidemiology, etiology and severity in relation to procedures which are not used(1414 Campoccia D, Montanaro L, Arciola CR. A review of the clinical implications of anti-infective biomaterials and infection-resistant surfaces. Biomaterials. 2013;34(33):8018-29.) . It is noteworthy here that there was no mention in any of the studies about extrinsic factors for surgical site infections, namely: hospital stay prior to the procedure, processing of items and materials for care, surgical techniques, or operating room environment. It is understood that these issues are already defined. Thus, it is considered that the studies have advanced towards knowledge and interventions of the intrinsic factors, i.e. age, severity and associated comorbidities, among others evaluated in the research that compose the sample for this review.

Finally, the administrative databases have been used frequently in comparative studies and setting improvement care goals (2222 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.,2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.) . However, attention must be turned to the quality of data available that suffer variations related to the type of record, specific causes of readmissions and quantitative information (2121 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.-2222 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.,2525 Zmistowski B, Respreto C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors.. J Bone Joint Surg Am 2013;95(20):1869-76.,2828 Kane P, Chen C, Post Z, Radcliff K, Orozco F, Ong A. Sazonality of infection rates after total joint arthroplasty. Orthopedics. 2014;37(2):182-6.) . Otherwise, limitations are imposed on studies (2424 Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets. J Neurosurg Spine. 2013;18(2):134-8.) , such as those cited by the selected authors: size and definition of the sample (2323 Nacke E, Ramos N, Stein S, Hutzler L, Bosco JA 3rd. When do readmissions for infection occur after spine and total joint procedures? Clin Orthop Relat Res. 2013;471(2):569-73.) and data loss due to inclusion criteria when patients are treated at other services other than those where the previous care occurred (2020 McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine (Phila Pa 1986). 2012;37(14):1260-6.

21 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients.J Bone Joint Surg Am 2013;95(11):1012-9.
-2222 McCormack R, Michels R, Ramos N, Hutzler L, Slover JD, Bosco JA. Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. J Healthc Manag. 2013;58(1):64-76.) . There is no doubt that measures or performance indicators from causes of readmission can be used in quality reports and accountability, given that their nature is multifactorial and responsibility must be shared (11 Morgan A, Khan A, Amin T. Challenges in evaluating all-cause hospital readmission measures for use as national consensus standards. Perm J. 2013;17(4):14-8.) .

This review also presents limitations due to the small number of selected publications, and in relation to the diversity of them, of assessing costs, sometimes comparing types of surgery, and always in very different situations. However, it is a first step in the multidisciplinary team of professionals that can provide the necessary importance to the data for better management and better qualification of the care provided.

Nurses in particular play an important role in improving the safety and quality of care, overseeing the results of critical managerial concepts throughout the historical movement of care (3131 Owens LD, Koch RW. Understanding quality patient care and the role of the practicing nurse. Nurs Clin N Am. 2015;50(1):33-43.).

Conclusion

It is noted that readmission rates become an important reference for analyzing the quality of care, especially when stratified by causes and time of occurrence is evaluated and compared with the previous hospitalization.

In relation to unplanned readmissions, SSI are the most frequent cause in more than half of the studies, although quite specific actions and widely publicized for its prevention and control, as well as extrinsic factors or related to care processes. When orthopedic surgeries are done, new admissions represent long hospitalization, invariably associated with new surgical interventions, an increase in the number of subsequent hospitalizations, and new infections.

The study of predictive risk factors already known and a review of work processes can change readmission data for orthopedic surgical site infections, reducing costs and qualifying assistance. Nursing care, in particular their management skills already established for critical care involving a multidisciplinary team, has a fundamental role in care, from comparative and analytical data of surgical procedures, to getting to know other dimensions with potential actions that contribute to minimize such occurrences.

This review has shown that research focuses on causes, risk factors and comparisons between institutions. However, there is the emergence of new elements, such as differences in the incidence of SSI between the various types of surgeries, which influence the incidence of SSI in overall rates and their meanings in the same institutions.

Still, a higher volume of comparative studies and new research involving issues related to indirect costs are necessary, specifically the social and psychological costs, closer to patients who are the victims of readmissions.

Nurses are health professionals with a prominent role in the control and prevention of infections, with fundamental in-depth knowledge that impacts the delivered care, minimizing the risk for SSI and therefore readmissions resulting from them.

Acknowledgements

Associate Professor of EEAN/UFRJ, Ph.D Antonio José de Almeida Filho, contributed in the preliminary critical analysis of the present review

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  • Financial support: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES. Process n. 99999.006522/2014-09

Publication Dates

  • Publication in this collection
    Dec 2015

History

  • Received
    04 Feb 2015
  • Accepted
    18 Aug 2015
Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br