Improving surgical site infection prevention practices through a multifaceted educational intervention.

As part of the National Clinical Programme on healthcare-associated infection prevention, a Royal College of Surgeons in Ireland (RCSI) and Royal College of Physicians of Ireland (RCPI) working group developed a quality improvement tool for prevention of surgical site infection (SS). We aimed to validate the effectiveness of an educational campaign, which utilises this quality improvement tool to prevent SSI in a tertiary hospital. Prior to the SSI educational campaign, surgical patients were prospectively audited and details of antibiotic administration recorded. Prophylactic antibiotic administration recommendations were delivered via poster and educational presentations. Post-intervention, the audit was repeated. 50 patients were audited pre-intervention, 45 post-intervention. Post-intervention, prophylaxis within 60 minutes prior to incision increased from 54% to 68% (p = 0.266). Appropriate postoperative prescribing improved from 71% to 92% (p = 0.075). A multifaceted educational program may be effective in changing SSI prevention practices.

The role of venous diameter in predicting arteriovenous fistula maturation: when not to expect an AVF to mature according to pre-operative vein diameter measurements? A best evidence topic.

This best evidence topic was investigated according to a described protocol. We asked the question: what is the minimal vein diameter that can successfully predict maturation of an arteriovenous fistula (AVF) in patients undergoing dialysis. Using the reported search 804 papers were found, of which five represented the best evidence to answer the clinical question. All studies assessed the association between successful AVF maturation and the size of vein used. The strongest evidence came from a nonrandomised controlled follow-up study in which 76% of fistulas created using >2 mm cephalic vein successfully matured compared to 16% when the vein measured ≤2 mm. Another prospective, multicentre study showed 65% successful maturation using veins >4 mm compared to 45% with veins <3 mm. Vein diameter was found to be an independent predictor of maturation in multivariate regression analysis in two retrospective observational studies. Another retrospective observational study found that using venous measurements of ≥2.5 mm following tourniquet application resulted in more fistulas been created that would have otherwise been denied based on venous ultrasound mapping. A large multicentre randomised clinical trial assessing the use of different vein sizes both with and without tourniquet application using proper statistical tools - such as receiver operating characteristic - is required to make a final recommendation. Until then, a vein diameter of <2.5 mm should be considered inadequate for formation of an AVF, particularly if those measurements remain unchanged following the use of tourniquet.

Should patients with infrainguinal arterial bypasses using autologous vein conduit undergo follow-up surveillance with duplex ultrasound?

This best evidence topic was investigated according to a structured format. The question asked was: should duplex ultrasound (DUS) scanning be a routine component of surveillance following infrainguinal arterial bypass using vein conduit? We performed a systematic literature search and identified 4 studies (3 randomised controlled trials and 1 meta-analysis) that provided the best evidence. The highest quality study was a multi-centre randomised controlled trial (n = 594). At 18 months following surgery, it found no difference in patency rates, amputations, vascular mortality or mortality. However it achieved just over half of anticipated recruitment and thus was underpowered. The remaining two randomised controlled trials had smaller sample sizes and methodological weaknesses and found conflicting results. Lundell et al. (n = 106) found improved primary assisted and secondary patency rates and fewer graft occlusions with a routine DUS policy. Ihlberg et al. (n = 152) found no difference in primary assisted patency or amputations although secondary patency was improved. A meta-analysis of mostly observational data (n = 6649) found fewer occlusions with routine DUS surveillance and no effect on amputations or mortality. Results are conflicting. The strongest evidence comes from the single high quality multi-centre trial. It appears as though routine DUS surveillance does not yield benefits in patient important outcomes. Further studies are needed.

Conservative management of mesh-site infection in hernia repair surgery: a case series.

PURPOSE: The aim of this study is to assess the outcome of conservative management of infected mesh grafts following abdominal wall hernia repair. METHODS: This study retrospectively examined the charts of patients who developed mesh-site infection following surgery for abdominal hernia repair to determine how effective conservative management in the form of antibiotics and wound management was on the resolution of infection and wound healing. RESULTS: Over a period of 30 months, 13 patients developed infected mesh grafts post-hernia repair surgery. Twelve patients were successfully treated conservatively with local wound care and antibiotics if clinically indicated. One patient returned to theatre to have the infected mesh removed. Of the patients that healed eleven were treated with negative pressure wound therapy (VAC(®)). CONCLUSION: This series of case studies indicate that conservative management of abdominal wall-infected hernia mesh cases is likely to be successful.

A comparison of fibrin sealant versus standard closure in the reduction of postoperative morbidity after groin dissection: A systematic review and meta-analysis.

BACKGROUND: Groin dissection is commonly performed in patients with lower limb malignant conditions such as malignant melanoma, vulvar, penile, anal and scrotal carcinomas with an associated high complication rate. Numerous surgical strategies have been suggested to reduce morbidity. We aimed to systematically review one of those methods - fibrin sealant (FS) - in comparison to standard closure (SC) in reducing postoperative morbidity from groin dissection. METHODS: A systematic search of the literature, study selection and data extraction using an independent screening process, assessment of risk of bias and statistical data analysis was performed. Only randomised controlled trials (RCTs) comparing fibrin sealant to standard care in patients with malignant disease undergoing groin dissection reporting at least one outcome measure relating to postoperative complications were included in the review. RESULTS: A total of 6 RCTs were included. There were no statistically significant differences in postoperative surgical site infection (SSI) rates between FS and SC. The overall incidence of wound infection in the FS group was 32% (43/133) compared to 34% (45/132) in the SC group. (Pooled risk ratio = 0.0.94 [0.68, 1.32]; 95% CI; P = 0.74). The incidence of seroma for the FS group (30/133) and the SC group (30/132) did not differ (Pooled risk ratio = 1.03 [0.67, 1.58]; 95% CI; P value = 0.90). Complication rates were similar between groups. CONCLUSION: Based on current evidence, fibrin sealant does not significantly reduce morbidity in patients undergoing groin dissection for the management of malignant disease when compared to standard closure techniques.

Diagnostic accuracy of non-radiologist performed ultrasound for abdominal aortic aneurysm: systematic review and meta-analysis.

BACKGROUND: Ultrasonography is increasingly used by clinicians to identify abdominal aortic aneurysms (AAA). We performed a systematic review and meta-analysis comparing the accuracy of non-radiologist performed ultrasound (NRPUS) for AAA disease to the 'gold standard' of radiologist performed aortic imaging (RPI), intra-operative findings or postmortem findings. METHODS: Cochrane Library, MEDLINE, EMBASE, SCOPUS-V.4, trial registries, conference proceedings, and article reference lists were searched to identify studies comparing NRPUS with RPI as the reference standard. Data abstracted from eligible studies was used to generate 2 × 2 contingency tables allowing calculation of pooled sensitivity and specificity values. RESULTS: 11 studies (944 patients) evaluated NRPUS for AAA detection. NRPUS had a pooled sensitivity of 0.975 [95% confidence interval (CI), 0.942-0.992] for AAA detection and a pooled specificity of 0.989 (95% CI, 0.979-0.995). CONCLUSIONS: Non-radiologist performed ultrasound achieves acceptable sensitivity and specificity for both detection and measurement of AAA. There was no evidence of significant heterogeneity with respect to pooled sensitivity or specificity.

Assessing the quality of online information for patients with carotid disease.

INTRODUCTION: Controversy exists relating to carotid endarterectomy (CEA) versus carotid artery stenting (CAS). We aimed to assess the quality of online patient information relating to both. METHODS: The Google search engine was searched for "carotid endarterectomy" and "carotid stenting". The first 50 webpages returned were assessed. The Gunning Fog Index (GFI) and Flesch Reading Ease Score (FRES) were calculated to assess readability. The LIDA tool (Minervation Ltd., Oxford, U.K.) was used to assess accessibility, usability and reliability. RESULTS: 20% (n = 10) of the webpages returned for CEA were from peer reviewed sources with 34% (n = 17) posted by hospitals or health services. Comparatively, for CAS, 40% (n = 20) were peer reviewed with 16% (n = 8) posted by hospitals or health services. GFI and FRES scores indicated webpages for both CEA and CAS had poor general readability. Webpages for CEA were easier to read than those for CAS (mean FRES difference of 6.7 (95% CI 0.51 to 12.93, p = 0.03). Median LIDA scores demonstrated acceptable reliability, accessibility and usability of information for both CEA and CAS webpages. The more readable webpages were not associated with higher LIDA scores for either CEA or CAS webpages. CONCLUSION: Webpages providing information on carotid disease management must be made more readable. Online information currently available to patients regarding CAS is more difficult to read and comprehend than CEA.

The impact of regional reconfiguration on the management of appendicitis.

BACKGROUND: Reconfiguration of surgical services in the Mid-West in 2009 resulted in a large increase in numbers of patients undergoing emergency surgery for appendicitis in University Hospital Limerick (UHL). AIMS: The aim of this study was to assess the impact of reconfiguration on the management of appendicitis in this area. METHODS: Data on all patients who underwent appendicectomy between January and June 2007 were compared with the corresponding data from January to June 2011. The numbers of operations, types of operations, lengths of stay (LOS), operation start times, rates of negative histology specimens and readmissions within 30 days were compared. One hundred and twenty-five appendicectomies [48 laparoscopic (38.4 %)] were performed in the 2007 group of which 32 specimens (25.6 %) were histologically negative. Three hundred and nineteen appendicectomies [238 laparoscopic (74.6 %)] were performed in the 2011 group of which 62 specimens (19.4 %) were histologically negative. The increase in numbers of laparoscopic procedures was significant (p < 0.001). The reduction in the negative appendicectomy rate was not statistically significant (p = 0.16). There were 10 conversions (20.8 %) to open surgery in the 2007 period and 12 (5 %) in the 2011 period (p = 0.001). Mean LOS for the 2007 and 2011 groups was 4.45 and 3.16 days (p < 0.001). Six (4.8 %) readmissions within 30 days occurred in the 2007 group with 20 (6.3 %) in the 2011 group (p = 0.66). CONCLUSION: Though reconfiguration of surgical services has resulted in a significant increase in workload, LOS has decreased significantly while maintaining acceptably low negative appendicectomy, conversion and readmission rates.

A descriptive cost analysis study of cases of right iliac fossa pain.

Patients with suspected appendicitis comprise a large proportion of general surgical workload. The resulting healthcare burden is significant when one considers that investigations, observation and surgical procedures are often needed. As no previous study has examined the cost of managing patients with suspected appendicitis, we performed a cost analysis study of management of cases of right iliac fossa (RIF) pain in University Hospital Limerick. Patients who were admitted with right iliac fossa pain from 1st April 2011 to 4th May 2011 were identified prospectively. After discharge, patients' medical records were reviewed. Costing data collected comprised details on length of stay, number and type of radiological investigations, number and type of blood investigations, medications administered and operations performed. Costs for radiological investigations were obtained from casemix data. Blood investigation costs were obtained from relevant laboratories. Medication costs were obtained from the pharmacy department. Operation costs were based on the cost of equipment combined with cost relating to operating theatre time and recovery unit time. Due to unavailability of data on Irish public hospital bed-day cost, a private hospital provided cost details on this aspect. 94 patients (M = 33, F = 61) were admitted with RIF pain during this time period. 62 underwent surgery. There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis. Blood test, radiology, pharmacy, operative and bed-day costs were €1857, €6252, €3517, €184,191 and €152,706 respectively. The total estimated cost was €348,525 (€3708 average per patient). There is a high cost associated with managing suspected appendicitis in Ireland. Strategies to reduce cost include reducing unnecessary admissions and unnecessary operations. Reducing LOS may be another potentially valuable cost saving method. It is imperative that resources are channelled into the provision of accurate costing structures.

Contrast-enhanced magnetic resonance angiography in diabetic patients with infra-genicular peripheral arterial disease: systematic review.

OBJECTIVE: Diabetes is a leading risk factor for the development of peripheral arterial disease (PAD). The optimal imaging modality for patients with diabetes and PAD is uncertain. We sought to analyse the literature to determine the accuracy of contrast enhanced magnetic resonance angiography (CE-MRA) in differentiating extent of disease in patients with infragenicular PAD and diabetes, using digital subtraction angiography (DSA) as the gold standard. METHODS: Online databases were searched for relevant keywords (January 1998-June 2012). Eligible studies prospectively compared CE-MRA and DSA of infragenicular vessels and provided data to construct contingency tables in at least 10 patients with diabetes and PAD symptoms. Pooled sensitivity and specificity values were calculated using random effects modelling. RESULTS: Only three studies (83 patients) provided data regarding the infragenicular vessels. The pooled sensitivity of MRA was 86% while the pooled specificity of MRA was 93%. CONCLUSIONS: The assumptions regarding CE-MRA's efficacy for infragenicular disease in diabetics are based upon low patient numbers. Inadequate diagnostic imaging in this high-risk group risks adoption of incorrect revascularisation strategies. Further studies are required.

Patient satisfaction following emergency admission via a surgical assessment unit and an emergency department.

AIM: Acute surgical patients are admitted to our regional hospital through the emergency department (ED) and through a new surgical assessment unit (SAU). The aim of this study was to compare the efficiency of the two units in seeing and assessing acute surgical patients, as well as patients' satisfaction with their experiences in both units. METHODS: A patient satisfaction scoring questionnaire was distributed to 115 consecutive surgical patients attending the SAU and ED over an 8-week period. Patients' impressions of waiting times, pain management and interactions with staff were detailed. The actual times taken for assessment, admission and discharge were recorded and compared with those perceived by the patients. RESULTS: Patients' perceptions of care were very high within both the ED and the SAU, with 95 % of SAU patients reporting their care as excellent or very good compared with 86 % of ED patients (p = 0.014). Patients were assessed considerably faster in the SAU compared with the ED, with an average wait from registration to admission or discharge totalling 5 h in the SAU compared with 12 h in the ED. CONCLUSION: The SAU provides an effective and efficient mode of assessment of acute surgical patients. While patients were discharged faster from the SAU than the ED, patients rated both units highly in terms of satisfaction with the service provided.

Improving patient care--the first year in a dedicated surgical assessment unit.

A surgical assessment unit (SAU) was established in October 2009 at the Mid-Western Regional Hospital. We assessed this servic in its initial year and compared it to Emergency Department (ED) services. We audited SAU and ED databases and theatre logbooks from November 2009 to October 2010. 1949 patients were referred to the SAU and 857 patients were admitted (44%). Only 44 SAU patients (6%) waited more than 6 hours for a bed compared to 828 patients (68%) admitted through the ED. SAU patients who required emergency surgery had a shorter waiting time before theatre (37 (18.6%) vs 9(6%) waited less than 6 hours, p < 0.05). To summarise, we found that almost 2,000 patients who would otherwise have presented to the ED were referred to the SAU. Waiting times for admission and theatre were significantly shorter. Further resource allocation could expand the service and improve it further, by diverting more patients from the ED.

An experimental study of prescribed walking in the management of venous leg ulcers.

OBJECTIVE: To determine the relationship between the level of patient activity in the form of walking and the rate of venous leg ulcer (VLU) healing. METHOD: Forty patients with newly diagnosed VLUs were recruited to the study a nd randomly allocated to either control or exercise groups. All patients were treated with multilayer compression bandaging for 12 weeks, or until their ulcer had fully healed. Daily stepping rate was recorded at initial assessment and following 4 weeks of treatment. Participants in the exercise group were encouraged to increase their daily steps with a target of 10 000 steps per day. The control group were n ot asked to change their daily steps. RESULTS: In total, 33% of the exercise group achieved an average of 10 000 steps per day. Participants who took more steps at both the baseline and 4-week assessment healed more quickly than those who took fewer steps (p=0.052 and p=0.008 for baseline and week 4, respectively). Sixty-seven per cent of the participants who increased their daily steps had venous ulcers, which were healed by week 8, compared with 35% of those who did not. CONCLUSION: Participants who took more steps per day showed faster venous ulcer healing times when compared with those who took fewer steps, emphasising the benefit of walking in this patient group. Further studies are necessary to confirm these early findings. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflict of interest to declare.

Can augmentation index be used as an accurate tool in the diagnosis of peripheral obstructive arterial disease?

BACKGROUND: The use of radial augmentation index (rAI) as an indicator of vascular disease was investigated in the vascular imaging laboratory in a regional hospital. AIMS: The aim of this study was to investigate whether a correlation exists between ankle-brachial pressure index (ABPI) and rAI in normal subjects, patients with peripheral obstructive arterial disease, and diabetic patients. METHODS: A group of 46 patients and 14 controls had ABPI and rAI measured and factors affecting AI were assessed. RESULTS: rAI was found to have a negative correlation with ABPI (Spearman's ρ = -0.513, p < 0.01). There was significant increase in the rAI scores of diabetic patients compared to normal patients (normal median was 64% lower than diabetic median, p < 0.01) and in peripheral obstructive vascular disease patients compared to normal (normal median 69% lower, p < 0.001). Of the various affecting factors, age stood out with rAI having a positive correlation to age (Spearman's ρ = 0.68, p < 0.01). CONCLUSIONS: The augmentation index appears be a significant indicator of cardiovascular disease and may be a useful tool in the diagnosis of vascular pathology.

Provision of general paediatric surgical services in a regional hospital.

BACKGROUND: In Ireland, specialist paediatric surgery is carried out in paediatric hospitals in Dublin. General surgeons/consultants in other surgical specialities provide paediatric surgical care in regional centres. There has been a failure to train general surgeons with paediatric skills to replace these surgeons upon retirement. AIM: To assess paediatric surgical workload in one regional centre to focus the debate regarding the future provision of general paediatric surgery in Ireland. METHODS: Hospital in-patient enquiry (HIPE) system was used to identify total number of paediatric surgical admissions and procedures. Cases assessed requiring hospital transfer. RESULTS: Of 17,478 surgical patients treated, 2,584 (14.8%) were under 14 years. A total of 2,154 procedures were performed. CONCLUSION: Regional centres without dedicated paediatric surgeons deliver care to large numbers of paediatric patients. The demand for care highlights the need for formal paediatric services/appropriate surgical training for general surgical trainees.

Changes in leg ulcer management practice following training in an Irish community setting.

OBJECTIVE: To identify regional changes in leg ulcer management following leg ulcer training for community-based nurses which incorporated Doppler ankle brachial pressure index (ABPI) assessment. METHODS: This was a two-part study conducted in the Irish Health Service Executive, Mid-Western Area. An initial audit in 2005 gathered details on all leg ulcer patients treated in the community in one week, including patient demographics, ulcer aetiology, assessment and treatment. The first audit was carried out before the introduction of a training course for community-based nurses in leg ulcer assessment and management. The training programme was delivered in 2005 and again in 2006. In total 30 public health nurses and community registered nurses from this region completed the course. The second part of the study involved repeating the audit in 2007. By comparing the results from 2005 with 2007 we were able to identify changes in leg ulcer assessment and management. RESULTS: A total of 426 and 449 leg ulcers were identified, with a prevalence of 0.12% and 0.1% in 2005 and 2007 respectively. Prevalence increased to 1.2% (2005) and 1.1% (2007) in those aged over 70 years. Most ulcers were venous in origin (63.3% in 2005 versus 68.8% in 2007). From 2005 to 2007 the number of venous leg ulcers treated with high compression increased significantly, by almost 16% (p < 0.0001). Once-weekly dressing changes increased by a significant 10%, reducing the number of dressings requiring more frequent changes (p = 0.002). CONCLUSION: Significant improvements in leg-ulcer practices were noted in the 18-month study period. The results show very significant increases in number of patients treated with high compression and a significant reduction in more than once-weekly dressing changes. These positive changes may be partly attributed to the enhanced knowledge and skills nurses gained by participating in training.

Natural history and clinical outcome of patients with documented carotid artery occlusion.

BACKGROUND: An occluded internal carotid artery (ICA) is considered a "safe artery" as it causes few symptoms. However, it has recently been suggested that spontaneous recanalisation of ICA occlusions may occur. AIM: To determine the incidence of ICA recanalisation among patients with a previously documented occluded ICA. METHODS: Patients with a documented ICA occlusion between September 2001 and January 2003 were identified. Patients who consented to participate had carotid duplex scans performed. Demographic and clinical data were collected. Statistical analyses were performed as appropriate. RESULTS: The total number of carotid duplex scans performed during the original study period was 719. An occluded ICA was identified in 30 (4.2%) patients. Of 19 patients who were rescanned two (11%) had recanalised a previously occluded ICA. CONCLUSIONS: Recanalisation occurs in a small number of patients who may need long-term surveillance.

Mobility in patients with venous leg ulceration.

OBJECTIVES: To compare mobility in patients with venous leg ulcers to matched controls and determine the influence of mobility, age and ulcer size on ulcer healing. METHODS: 25 leg ulcer patients, and 25 matched controls wore a mobility monitor (ActivPAL, PAL Technologies Ltd, Glasgow, Scotland)) which recorded the number of steps and amount of time spent walking, standing, sitting or lying for a one-week period. A walking index was calculated. The ulcer group were treated with compression bandaging and ulcer healing recorded over 12 weeks. RESULTS: There were 13 female subjects in each group. The median age was 70.5 (range 30-89) years. There was no difference in the amount of time either group spent standing, walking and resting. There was a significant reduction in the number of steps taken and in the walking index in the ulcer group compared to controls (ulcer group, median 6,685 steps/day, range 2074-17,999; control group median 8750, range 4917-16,043, p<0.05, Mann Whitney u test). Smaller ulcers and ulcers of recent onset were most likely to heal within 12 weeks (p=0.005 and p=0.011 respectively, Chi squared test). The percentage of time spent mobilising and resting did not influence ulcer healing (r(s)=-0.125; p=0.55). CONCLUSIONS: Mobility patterns among patients with leg ulcers are not significantly different to age matched controls. Ulcer patients take fewer steps per week compared to controls indicating they have reduced calf muscle pump function. Further studies are required to determine whether therapies which increase calf muscle activity have a role in ulcer treatment.

An exploration of current leg ulcer management practices in an Irish community setting.

OBJECTIVE: To establish the prevalence of leg ulceration in the Irish Health Service Executive (HSE) mid-western region and to determine the level of assessment and treatment patients have been receiving in the local community. METHOD: Before the introduction of a Doppler training programme, all public health and community health nurses working in the Irish HSE mid-western area were requested to complete an audit form on each patient being treated for leg ulceration during a predefined one-week period. This form recorded details on patient demographics, ulcer aetiology, assessment and treatment. Out of 97 nurses, 96 responded to this audit, giving a response rate of 98.9%. RESULTS: A total of 429 patients with 449 leg ulcers were identified. Mean age was 75.5 years (standard deviation 10.7). Overall prevalence was 0.12%, which increased to 1.2% in those aged 70 years and over. Women were almost twice as likely as men to be affected (ratio of 1.8:1). The main causes of ulceration were reported as venous incompetence accounting for 63.3% (284/449) and arterial insufficiency accounting for 8% (36/449) of all ulcers. Only 59.9% (269/449) of all ulcerated limbs had ABPI measurements performed. Of those reported as venous in origin, 71.8% (204/284) had ABPI measurements recorded. Evidence-based care was generally apparent in this group, with 47.5% (97/204) receiving high compression and 18.1% (37/204) receiving reduced compression. However, in venous leg ulcers where ABPIs were not recorded (n=80) care appeared haphazard and inappropriate. CONCLUSION: Our study has identified the benefit of ABPI Doppler assessment.This assessment could be done in local health centres by trained nurses who could provide more appropriate and timely care to patients, thereby improving outcomes and relieving pressure on acute hospital clinics.

Popliteal-to-distal artery bypass for diabetic limb salvage.

BACKGROUND: Poor long-term survival and significant co-morbidity among diabetic patients with limb ischaemia makes the shortest, simplest revascularisation procedure desirable. AIM: Evaluate limb salvage, primary graft patency and peri-operative morbidity rates in diabetic patients undergoing popliteal-to-distal artery bypass for limb salvage. METHODS: Patients undergoing popliteal-to-distal artery bypass for critical limb ischaemia over a seven-year period were retrospectively identified. Patients operative and follow-up data were entered into a database and limb salvage and patient survival determined using Kaplan Meier survival analysis. RESULTS: During the study period 21 popliteal-to-distal artery bypasses were performed on 19 diabetic patients. Mortality rate after one year was 11%. Primary graft patency rates among surviving patients was 81%, 67% and 48% at 1, 2 and 6 years respectively. Amputation was required in three patients. CONCLUSION: Popliteal-to-distal artery bypass produces favourable results in high-risk diabetic patients with critical limb ischaemia.