Cost benefit analysis of same day pregnancy tests in elective orthopaedic surgery.

UNLABELLED: We reviewed the results of 4,723 day of surgery pregnancy tests performed at two of our institution's locations, our ambulatory surgery center and our acute orthopaedics hospital over a 23 month time period. All patients were scheduled for elective orthopaedic surgery. There were seven positive results (0.15%) and one false negative result (0.02%). The cost per positive result for both hospital locations was $1,005.32. INTRODUCTION: Performing elective surgery on pregnant women can harm the mother and fetus. In order to minimize the likelihood of this happening, we administer a urine pregnancy test to each woman of childbearing age on the date of surgery. From November 2009 to September 2011, we performed 4,723 urine human chorionic gonadotropin (hCG) pregnancy tests on the day of surgery. We reviewed the results and cost of each pregnancy test. We then used these results to calculate the percentage of positive tests and the cost of diagnosing each pregnant female on the date of their surgery. METHODS: We obtained the records of all urine hCG pregnancy tests performed from November 2009 to September 2011. Each test was reviewed to determine if the result was positive or negative. Costs were calculated using the charges incurred for a qualitative hCG pregnancy test. We then contacted each patient with a positive result to determine if the urine hCG test results were accurate. RESULTS: 4,723 pregnancy tests were reviewed over a 23 month period with 7 (0.15%) having a positive result. Over the 23 month time period, we were notified of one false negative result (0.02%). The Positive Predictive Value (PPV) was 100% and the Negative Predictive Value (NPV) was 99.9%. The cost of a single urine hCG test was $1.49, the total cost for all 4,723 tests was $7,037.27. The cost of diagnosing 7 positive tests was $1,005.32. CONCLUSION: Routinely performing urine hCG pregnancy tests on the day of surgery is a cost effective method of preventing elective orthopaedic surgery on pregnant women. Of 4,723 women tested 7 had a positive result and 1 had a false negative result. The cost of $1,005.32 for each positive test must be compared with the benefit of not performing elective surgery on a pregnant female.

Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution.

BACKGROUND: Treatment of Staphylococcus aureus colonization before surgery reduces risk of surgical site infection (SSI). The regimen of nasal mupirocin ointment and topical chlorhexidine gluconate is effective, but cost and patient compliance may be a barrier. Nasal povidone-iodine solution may provide an alternative to mupirocin. METHODS: We conducted an investigator-initiated, open-label, randomized trial comparing SSI after arthroplasty or spine fusion in patients receiving topical chlorhexidine wipes in combination with either twice daily application of nasal mupirocin ointment during the 5 days before surgery or 2 applications of povidone-iodine solution into each nostril within 2 hours of surgical incision. The primary study end point was deep SSI within the 3 months after surgery. RESULTS: In the modified intent-to-treat analysis, a deep SSI developed after 14 of 855 surgical procedures in the mupirocin group and 6 of 842 surgical procedures in the povidone-iodine group (P = .1); S. aureus deep SSI developed after 5 surgical procedures in the mupirocin group and 1 surgical procedure in the povidone-iodine group (P = .2). In the per protocol analysis, S. aureus deep SSI developed in 5 of 763 surgical procedures in the mupirocin group and 0 of 776 surgical procedures in the povidone-iodine group (P = .03). CONCLUSIONS: Nasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01313182.

A hospital-wide initiative to eliminate preventable causes of immediate use steam sterilization.

Instruments and implants sterilized by immediate use steam sterilization (IUSS), formerly called flash sterilization, can increase the patient's risk for acquiring a surgical site infection. We implemented a hospital-wide initiative to determine the reasons that perioperative personnel use IUSS to sterilize items and then designed a program to reduce the hospital's rates. Program initiatives included educating perioperative personnel, improving scheduling processes, holding vendor discussions, purchasing additional instrument sets, and transitioning from paper wrap to metal containers for instrument sets. In addition, we instituted a policy whereby nursing leaders are required to approve IUSS before it can be used and developed guidelines for immediate and rapid processing in the sterile processing department, and we monitor compliance daily and communicate results regularly to all team members. These efforts decreased our facility use of IUSS for implants from 10.22% in January 2008 to 0.09% in August 2012, and we decreased our use of IUSS for instruments from 79% in May 2010 to 7.5% in February 2012. We simultaneously implemented a process to reduce surgical site infection rates and saw an improvement in surgical site infection from 5.4% in the first quarter of 2010 to 1.4% in the fourth quarter of 2012.