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Original Investigation | Pacific Coast Surgical Association

Risk Factors for Superficial vs Deep/Organ-Space Surgical Site Infections:  Implications for Quality Improvement Initiatives

Elise H. Lawson, MD, MSHS1; Bruce Lee Hall, MD, PhD, MBA2,3,4,5,6; Clifford Y. Ko, MD, MS, MSHS1,6,7
[+] Author Affiliations
1Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles
2Department of Surgery, Washington University School of Medicine, St Louis, Missouri
3Barnes Jewish Hospital, St Louis, Missouri
4St Louis Veterans Affairs Medical Center, Center for Health Policy, St Louis, Missouri
5Olin Business School, Washington University, St Louis, Missouri
6Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
7VA Greater Los Angeles Healthcare System, Los Angeles, California
JAMA Surg. 2013;148(9):849-858. doi:10.1001/jamasurg.2013.2925.
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Published online

Importance  Surgical site infections (SSIs) are the focus of numerous quality improvement initiatives because they are a common and costly cause of potentially preventable patient morbidity. Superficial and deep/organ-space SSIs differ in terms of anatomical location and clinical severity.

Objective  To identify risk factors that are uniquely predictive of superficial vs deep/organ-space SSIs occurring after colectomy procedures.

Design  Retrospective cohort study.

Setting  American College of Surgeons National Surgical Quality Improvement Program.

Participants  Patients undergoing colectomy procedures in 2011 were identified by Current Procedural Terminology codes.

Intervention  Colectomy procedures.

Main Outcomes and Measures  We compared rates of superficial SSI and deep/organ-space SSI associated with perioperative variables of interest: demographics; preoperative clinical severity, risk factors, and comorbidities and variables related to the hospitalization or procedure. Hierarchical multivariable logistic regression models were developed to identify risk-adjusted predictors of each SSI type.

Results  Among 27 011 patients identified from 305 hospitals, 6.2% developed a superficial SSI and 4.7% developed a deep/organ-space SSI. Risk factors common to the occurrence of both SSI types were identified: open surgery (vs laparoscopic) and current smoker. Risk factors with differential effects on each SSI type included specific postoperative diagnoses, disseminated cancer, and irradiation therapy, which were all associated with increased odds of deep/organ-space SSI only. The graded relationship between increasing body mass index and SSI occurrence appeared to be stronger for superficial SSI.

Conclusions and Relevance  Risk factors for superficial SSI and deep/organ-space SSI vary in terms of magnitude and significance, suggesting that these SSI types are somewhat different disease processes. Groups interested in preventing SSIs might improve success by considering these SSI types independently for root-cause analyses and development of best practices and interventions.

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