Objective Surgical site infection (SSI) is one of the most common post-operative complications following vascular reconstruction, producing significant morbidity and hospital readmission. In contrast to SSI that develops while patients are still hospitalized, little is known about the cohort of patients that develop SSI following discharge. In this study, we explore the factors that lead to post-discharge SSI, investigate the differences between risk factors for in-hospital versus post-discharge SSI, and develop a scoring system to identify patients that might benefit from post-discharge monitoring of their wounds. Methods Patients who underwent major vascular surgery from 2005–2012 for aneurysm and lower extremity occlusive disease were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Patients were categorized as having no SSI, in-hospital SSI, or SSI after hospital discharge. Predictors of post-discharge SSI were determined by multivariable logistic regression and internally validated by bootstrap resampling. Risk scores were assigned to all significant variables in the model. Summative risk scores were collapsed into quartile-based ordinal categories and defined as low-, low/moderate-, moderate/high-, and high-risk. Multivariable logistic regression was used to determine predictors of in-hospital SSI. Results Of the 49,817 patients who underwent major vascular surgery, 4,449 (8.9%) were diagnosed with SSI (2.1% in-hospital; 6.9% post-discharge). By multivariable analysis, factors significantly associated with increased odds of post-discharge SSI include female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, neurological disease, prolonged operative time >4 hours, American Society of Anesthesiology classification IV or V, lower extremity revascularization or aortoiliac procedure, and groin anastomosis. The model exhibited moderate discrimination (bias-corrected c-statistic, 0.691) and excellent internal calibration. The post-discharge SSI rate was 2.1% for low-risk patients, 5.1% for low/moderate-risk patients, 7.8% for moderate/high risk patients, and 14% for high-risk patients. In a comparative analysis, comorbidities were the primary driver of post-discharge SSI whereas in-hospital factors (operative time, emergency case status) and complications predicted in-hospital SSI. Conclusions The majority of SSIs after major vascular surgery develop following hospital discharge. We have created a scoring system that can select a cohort of patients at high-risk for SSI following discharge. These patients can be targeted for transitional care efforts focused on early detection and treatment with the goal of reducing morbidity and preventing readmission secondary to SSI.
Background Information technology is transforming healthcare communication. Using smartphones to remotely monitor incisional wounds via digital photos as well as collect post-operative symptom information has the potential to improve patient outcomes and transitional care. We surveyed a vulnerable patient population to evaluate smartphone capability and willingness to adopt this technology. Methods We surveyed 53 patients over a 9-month period on the vascular surgery service at a tertiary-care institution. Descriptive statistics were calculated to describe survey item response. Results 94% (50 out of 53) of recruited patients participated. The cohort was 50% female, and the mean age was 70 years old (range: 41–87). The majority of patients owned cellphones (80%) and 23% of these cellphones were smartphones. 90% of patients had a friend or family-member that could help take and send photos with a smartphone. 92% of patients reported they would be willing to take a digital photo of their wound via smartphone (68% daily, 22% every-other day, 2% less than every-other day, 8% not at all). All patients reported they would be willing to answer questions related to their health via smartphone. Patient’s identified several potential difficulties with regard to adopting a smartphone wound-monitoring protocol including logistics related to taking photos, health-related questions, and coordination with caretakers. Conclusions Our survey demonstrates that an older patient cohort with significant comorbidity is able and willing to adopt a smartphone-based post-operative monitoring program. Patient training and caregiver participation will be essential to the success of this intervention.
Objective Surgical site infection (SSI) is the most common nosocomial infection, particularly in vascular surgery patients who experience a high rate of readmission. Facilitating transition from hospital to outpatient care with digital image-based wound monitoring has the potential to detect and enable treatment of SSI at an early stage. In this study we evaluate whether smartphone digital images can supplant in person evaluation of postoperative vascular surgery wounds. Methods We developed a wound assessment checklist using previously validated criteria. We recruited adults who underwent a vascular surgical procedure between 2014 and 2015, involving an incision of at least 3cm in size from a high-volume academic vascular surgery service. Vascular surgery care providers evaluated wounds in person using the assessment checklist; a different group of providers evaluated wounds via a Smartphone digital image. Inter-rater agreement coefficients (AC) for wound characteristics and treatment plan were calculated within and between 1) the in-person group and 2) the digital image group; the sensitivity and specificity of digital images relative to in person evaluation were determined. Results We assessed a total of 80 wounds. Regardless of modality, inter rater agreement was poor to when evaluating wounds for the presence of ecchymosis and redness, moderate for cellulitis and high for the presence of a drain, necrosis or dehiscence. As expected, the presence of drainage was more readily observed in person. Inter rater agreement was high for both in-person and image-based assessment with respect to course of treatment, with near-perfect agreement for treatments ranging from antibiotics to surgical debridement to hospital readmission. No difference in agreement emerged when raters evaluated poor-quality compared to high-quality images. For most parameters, specificity was higher than sensitivity for image-based compared to gold-standard in-person assessment. Conclusions Using Smartphone digital images is a valid method for evaluating postoperative vascular surgery wounds and is comparable to in-person evaluation with regard to most wound characteristics. The inter-rater reliability for determining treatment recommendations was universally high. Remote wound monitoring and assessment may play an integral role in future transitional care models to decrease readmission for SSI in vascular or other surgical patients. These findings will inform smartphone implementation in the clinical care setting as wound images transition from informal clinical communication to becoming part of the care standard.
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