Wpływ czynników ryzyka zakażenia związanego z opieką zdrowotną na wystąpienie zakażenia miejsca operowanego u pacjentów geriatrycznych po zabiegach ortopedycznych

Introduction

Operational procedures, regardless of the surgical specialty, are invasive procedures with which the high risk of various medical events is associated, including healthcare infections. The European Center for Disease Prevention and Control (ECDC) reports that each year in Europe, over 3.2 million patients are diagnosed with a healthcare associated infection (HAI), and the costs of treating these infections vary ranges from EUR 13-24 billion [1].

The risk of HAI depends on the microorganism, the patient and the hospital environment. HAI acquired during treatment cause complications of the underlying disease, cause the extension of the hospital stay and increases the costs of treatment. The occurrence of infections is an objective indicator of the quality of services rendered, and monitoring of infections affects the increase in care quality. When cutting the patient’s skin and subcutaneous tissue during surgery, microorganisms may contact exposed sterile tissues, and then multiply, which leads to the infection of the operated place (SSI) in the postoperative period. Based on the CDC NNiss guidelines (United States Center for Disease Control National Nosocial Infections Surveillance System), SSI is divided into surface infections (skin and subcutaneous tissue), deep infections (fascia and muscles) and organ infections (distant from the cutting place) [2] . Infections of operated in patients of trauma and orthopedic surgery limit their successes and are associated with serious consequences [3]. Point examination of infections related to healthcare and the use of antibiotics in hospitals working in the system of acute duty (PPS HAI & AU) in Poland - a report from a study conducted in 2014-2015 states that the occurrence of infections after orthopedic procedures is in the range of 4.5% in 2014 up to 5.3% in 2015.

The demographic changes observed in recent years indicate that the aging process of society in Poland is progressing. In the years 1990–2021, the number of people in post -working age (men 65 and more, women 60 years and more), whose participation in the overall population in 2021 was 22.5% (8.5 million people), which binds with the risk of musculoskeletal disease and emergency conditions associated with the fall and the need for surgery [4,5]. The creation of SSI depends on many factors whose knowledge allows you to implement deliberate preventive measures. SSI risk factors are divided into non -modifiable, e.g. age and comorbidities and modifiable diseases, among others nutrition and smoking. Modificable risk factors from the patient should be taken into account already at the patient’s qualification stage for surgery [6-8]. Introduction to the patient’s medical documentation an assessment of the risk of infection at admission to the hospital is a requirement arising from applicable legal acts [9,10]. The assessment of the risk of infection is an extension of the patient’s subject and subjective examination aimed at estimating the risks associated with the planned scope of activities during hospitalization.

Objective of the work

The aim of the study was to assess the impact of risk factors for hospital infections on the occurrence of infections of the place operated in the orthopedics department.

Material and methods

The study was conducted in the department of orthopedics and traumatology of the musculoskeletal system in the period from January 2022 to December 2022. In the analyzed period, 1019 surgical procedures were performed in the ward.

In all patients, within 12 hours of admission, HAI risk was assessed using the assessment form of risk factors for infection at admission to the hospital. 29 risk factors were assessed, among others: age equal or over 75 years; transfer from another hospital, nursing home or hospitalization in the last 6 months; surgical procedures, invasive tests performed less than 6 months before hospitalization; alarm microorganism carrier; hygiene neglect; previously passed infections related to hospital stay below 12 months; artificial roads: urethra, stoma, vascular catheter; immobilization; recurrent inflammatory processes; chronic infections; active acute infection; pressure sores; antibiotic therapy below 3 months before hospitalization; current radiation therapy, chemotherapy, steridotherapy; eating disorders, malnutrition, swallowing disorders and others.

The analysis of risk factors for infections for the occurrence of operated place infections was carried out thanks to a review of medical and nursing medical records, analysis of microbiological examinations, analysis of antibiotic therapy and observation of the patient after surgery: feverish patients, observation cards of the operated place. The research uses the passive and active method of monitoring infections related to healthcare. The analyzed data was applied to the observation questionnaire - a comparative analysis of the collected data was made. Descriptive statistics such as average, median, minimum, maximum, lower and upper quarter and standard deviation were used for the description of continuous variables. Category variables are described with the help of percentage values. With the help of the Shapiro-Wilka test, it was checked whether continuous variables have a normal distribution. The Manna-Whitney test was used to examine the differences between continuous variables. The Chi2 test was used to examine the relationship between two nominal variables (with YEATS correction if required). All calculations were made with the help of MS Excel, Statistica 13.0 programs at the level of Alfa significance equal to 0.05.

Results

Statistical analysis covered a group of 1019 patients of the orthopedics and traumatology department of the musculoskeletal system. In the period from January 2022 to December 2022, 1019 surgical treatments were performed, 541 in women (53.09%) and 478 in men (46.91%). The procedure due to the original cokertosis was performed in 309 patients, which constituted 30.32%of all treatments performed during the period, primary bilateral cokertose in 342 (33.56%), shoulder damage to 58 (5.69%), lower limb fractures in 107 (10.5%), transmittar fractures in 138 (13.54%), dupuytren’s contracture in 61 (5.99%) and due to recurrent patella in 4 patients (0.39%). The average age of patients operated in the analyzed period was 65 years (minimum 19 and maximum 94 years), 29 people were over 75 years old (2.85%).

The average length of hospitalization was 5.7 days (minimum 0 and maximum 58 days). The hospitalization of patients accepted for planned procedures was shorter than the hospitalization of patients adopted in sudden mode, diagnosed with Przekarietaric fracture and older patients.

Each patient up to 12 hours from the moment of admission to the ward had a risk assessment of hospital infection. Based on the information obtained, patients were qualified to one of the three risk groups of hospital infection (group and low risk - up to 4 points, group II average risk - up to 7 points, group III High risk - 8-10 points). The average HAI risk assessment result was 2.95 points (minimum 0 and maximum 14).

In the analyzed group of Patients SSI was detected in 14 people, which shapes the incidence rate of 1.37%. The most common etiological factor insulated from patients with SSI was Staphylococcus Aureus MSSA.

Comparative analysis of patients in whom SSI developed and without infection showed a statistically significant difference between the admission mode and the occurrence of infection -test CI2 (1) = 5.06; P = 0.02451. Among the people adopted in planned mode, the infection occurred in 9 people (1.03%), and among the persons adopted in urgent mode infections occurred in 5 people (3.36%).

An important risk factor is age. In a group of patients with an infection of the place operated over the age of 75, the infection occurred in 5 people (17.24%). A statistically significant difference in the occurrence of infection due to age above and under 75 - test Chi2 (1) = 55.46 was observed; P = 0.00001. Details are presented in Table 1.

A statistically significant difference in the occurrence of infection was observed due to the transfer from another hospital or not - the Chi2 test (1) = 24.36; P = 0.00001. Among the people admitted to the house in 11 patients, SSI developed (1.10%), and among people moved from another hospital infections occurred in 3 people (18.75%). Details are presented in Table 2.

A statistically significant difference in the occurrence of infections was observed due to hygienic neglect/urine incontinence/faecal incontinence - test chi2 (1) = 14.83; p = 0.00012. Among people who did not have hygiene neglect/urinary incontinence/stool incontinence, SSI developed in 11 patients (1.08%), and among people who had hygiene neglect/urinary incontinence/non -stool incontinence, infection occurred in 3 patients (12.50 %). Details are presented in Table 3.

A statistically significant difference in the occurrence of infections was observed due to the occurrence of artificial roads (urinary catheter, stoma, vascular catheter, tracheal tube) - test Chi2 (1) = 8.04; P = 0.00457. Among people who did not have a urinary catheter, stoma, vascular catheter and SSI tracheal tube, 10 patients (1.05%) developed, and among people who had artificial roads to SSI took place in 4 people (6.06%). Details are presented in Table 4.

A statistically significant difference in the occurrence of infections was observed due to the occurrence of an open injury/internal injury - test Chi2 (1) = 37.01; P = 0.00001. Among the people who did not have SSI injuries, 10 patients (1.00%) developed, and among people who had injury infected occurred in 4 people (19.05%). Details are presented in Table 5.

A statistically significant difference in the occurrence of infections was observed due to the occurrence of recurrent inflammatory processes - the Chi2 test (1) = 14.07; p = 0.00018. Among people who did not have recurrent inflammatory processes, SSI developed in 11 patients (1.11%), and among people who had recurrent inflammatory processes infected occurred in 3 people (12.00%). Details are presented in Table 6.

A statistically significant difference in the occurrence of infections was observed due to the occurrence of an active acute infection - the Chi2 test (1) = 5.19; p = 0.022688. Among people who did not have an active acute SSI infection developed in 13 patients (1.28%), and among people who had active acute infection infection occurred in one person (33.33%). Details are presented in Table 7.

A statistically significant difference in the occurrence of infections was observed due to the occurrence of pressure ulcers/lesions on the skin - test Chi2 (1) = 53.11; P = 0.00001. Among people who did not have pressure ulcers/changes on the skin, the development of SSI occurred in 11 patients (1.09%), and among people who had pressure sores/lesions on the skin infected occurred in 3 people (37.50%). Details are presented in Table 8.

A statistically significant difference in the occurrence of infections was observed due to the occurrence of eating disorders/malnutrition/swallowing disorders - CH2 test (1) = 8.26; P = 0.00406. Among people who did not have eating disorders/malnutrition/swallowing disorders to the development of SSI occurred in 13 patients (1.28%), and among people who had eating disorders/malnutrition/malnutrition/swallowing disorders infection occurred in 1 person (50.00% ). Details are presented in Table 9.

Other analyzed risk factors also had an impact on the occurrence of operated infection in the operated infection: antibiotic therapy <3 months before hospitalization-CH2 test (1) = 5.19; p = 0.02268; occurrence of current radiotherapy/chemotherapy/steridotherapy - test Chi2 (1) = 5.19; p = 0.02268; occurrence of blood coagulation/transfusion disorders <6 months-test chi2 (1) = 5.19; p = 0.02268; occurrence of metabolic disease - CH2 test (1) = 29.20; p = 0.00001; Occurrence of alcoholism/other addictions from intoxicants, drugs - CH2 test (1) = 8.26; p = 0.00406; smoking> 10 cigarettes per day - CH2 test (1) = 20.92; p = 0.00001; ischemic heart disease/unpaid/circulatory failure - CH2 test (1) = 15.67; p = 0.00008; Achemic limb disease/Core syndrome - CH2 test (1) = 8.25; p = 0.00406; chronic renal failure/dialysis - test chi2 (1) = 17.46; p = 0.00003; occurrence of COPD/Asthma/respiratory failure - CH2 test (1) = 15.67; p = 0.00008; risky behaviors/mental disorders/dementia/entanglement - CH2 test (1) = 5.19; p = 0.02268; Operational treatments/invasive tests performed shorter <6 months before hospitalization-CH2 test (1) = 4.92; P = 0.02657.

The own study was analyzed by 29 risk factors for the occurrence of SSI, the analysis of these factors showed that the impact on the occurrence of SSI among 1019 patients operated in the ward in the period from January 2022 to December 2022 did not have the following from the analyzed risk factors: type of diagnosis - CH2 test ( 6) = 8,623; p = 0.19591655; Type of Chi2 (4) = 0.01; p = 0.00001; Chronic prostate hypertrophy/urine outflow/urinary incontinence - CH2 test (1) = 3.67; p = 0.05544; Cancer occurrence - CH2 test (1) = 2.15; p = 0.14189; unconscious/after choking/after NZK/immobilization - test chi2 (1) = 3.67; p = 0.05544; The patient’s place of residence and sex also did not affect the occurrence of SSI.

Discussion

The risk assessment of infection should take into account the risk factors associated with the patient and the procedure (preoperative, intraoperative and postoperative). Among the SSI risk factors, you can distinguish those undergoing modifications and those that cannot be modified. The frequency of surgical wound infections is from 1.5% in the absence of risk factors up to 13% in patients with 3 risk factors [2,6,11]. In their own research, patients who found risk factors for hospital infection were statistically more likely to infection (median 3) than patients who did not detect any risk factors (median 0). Analysis of the obtained data in studies carried out at the Orthopedics and Traumatology Department of Movement Among 1019 patients operated in the period from January 2022 to December 2022, it showed that among the studied group of patients infection was detected in 14 people (1.37%), without infection there were 1005 people (98.63%). Point examination of infections related to healthcare and the use of antibiotics in hospitals working in the system of acute duty (PPS HAI & AU) in Poland - a report from a study conducted in 2014-2015 states that the occurrence of infections after orthopedic procedures is in the range of 4.5% in 2014 up to 5.3% in 2015. In the research of WZYŁEK et al. The incidence of SSI in 6261 patients undergoing orthopedic procedures in 2014-2018 was 1.8%, etiological factors most often isolated from patients with SSI were Staphylococcus aureus, coagulazocymatic staph and Klessiella pneumoniae [12]. In self -study, the most common etiological factor SSI was Stpahylococcus Aureus MSSA. The Słowik was observed in the observation of 2340 patients undergoing surgery, including: 1756 hip arthroplastics (HPRO) and 584 knee arthroplastics (KPRO). 37 SSI cases were detected in the examined group of patients, including: 26 cases of SSI after HPRO and 11 cases in KPRO. The average incidence of SSI was 1.6% [13].

Age is an non -modifiable hai risk factor. In particular, persons over 65 years of age are susceptible to the occurrence of infection, in whom many physiological processes and reduction of the synthesis of immune proteins and factors participating in the wound healing process facilitates colonization and development of infection [14,15]. In studies carried out by Jinbo et al. The incidence of infection of the operated place in a geriatric patient after orthopedic surgery is 2.7%. According to Jinbo et al. Complications after orthopedic surgery in the elderly have now become a serious challenge for orthopedists. Geriatric patients may be accompanied by co -existing diseases, and the aging skin and soft tissues are usually fragile and less tolerant of surgical injury [16]. In own research, 64.2% of patients in whom SSI developed was over 75 years old.

The elongated time of the patient’s stay before surgery in the hospital is associated with the risk of colonization of hospital strains, which occurs within 24-48 hours of admission of the patient to the hospital [17,18]. The analysis carried out in Jinbo et al. Studies showed that the length of the stay has an impact on the occurrence of SSI. The average hospitalization time of patients with SSI and uninhabited patients was 30.6 ± 19.2 days and 16.9 ± 10.1, respectively, and the difference was statistically significant (P, 000.3) [16]. In own research, a statistically significant difference in the length of hospitalization was observed due to the occurrence of infection or not-Manna-Whitney test-p = 0.048101. The median length of stay for people without infection was 5 days, and the median for people with 6 days infection. Longer hospitalization also had an impact on the development of SSI.

An important element in the preparation of the patient for surgery is the identification of active infections, such as urinary tract infection, pneumonia, sinus, recurrent boys and pressure sores, which are a potential source of surgery infection. In own research, a statistically significant difference in infections was observed due to the occurrence of an active acute infection - test Chi2 (1) = 5.19; p = 0.022688. Among people who did not have an active acute infection 13 had an infection (1.28%), and among people who had active acute SSI infection occurred in one person (33.33%). If the procedure is in planned mode, the infection should be cured before surgery, in the case of urgent procedures, empirical antibiotic therapy should be implemented, and after obtaining microbiological testing results, targeted therapy [17]. Own research also showed a statistically significant difference in the occurrence of infections due to the occurrence of recurrent inflammatory processes - test Chi2 (1) = 14.07; p = 0.00018. Among people who did not have recurrent inflammatory processes, SSI developed in 11 patients (1.11%), and among people who had recurrent inflammatory processes infected occurred in 3 people (12.00%). In order to identify potential infections beforePlanned surgical procedures, especially in the case of planned implantation of a foreign body, is indicated, among others Execution of urine culture, dental consultation (pantomograph to exclude peri -surface teeth infection) and gynecological consultation in the case of women [6,17,18]. Own research has shown that the occurrence of pressure sores in patients admitted to the ward is a risk factor for SSI. In 6.12% of patients who had pressure sores, SSI occurred, while in patients without pressure ulcers SSI occurred in 1.13%. The risk of these people is associated with colonization of multi -sales bacteria and prolonged immobilization, which is associated with worse recovery after surgery.

In the prevention of SSI, an important role is played by a proper assessment of risk factors performed by a doctor. A difference was observed in the occurrence of SSI between patients adopted to the ward in planned and urgent mode. Among the persons adopted in planned mode, the infection occurred in 1.03%, and among the persons adopted in urgent mode infection occurred in 3.36%. This is related to the method of preparing the patient for surgery. In the case of planned surgical procedures, the patient’s preparation for surgery begins in outpatient conditions. The assessment of the patient’s general physical and mental condition at the stage of the outpatient clinic allows the identification of risk factors for infections, the implementation of educational activities focused on prevention and conscious participation of the patient in the treatment process. A very important element of SSI prevention is the preparation of the patient for the procedure performed by the nursing team. Each patient has a clean hospital bed and pure bedding underwear, the departmental nurse is responsible for the implementation and compliance with the subordinate staff of hygiene procedures related to the purity of bed and bedding in the ward and ensuring disinfectant preparations. Every patient on the eve and morning on the day of surgical surgery has a whole body bath using detergents containing a substance with confirmed effectiveness with antibacterial and anti -fungal effect, and before the procedure dresses into pure surgery. A two -time preoperative bath with disposable washers and detergent containing a substance with confirmed antibacterial and antifungal effect, as well as pure operational clothing reduces the microflora of the skin and leads to a decrease in the incidence of infections of the operated place. Wałość from the operating field is removed only in situations where the presence of hair can be an obstacle during surgery, not earlier than 1-2 hours before surgery. According to the authors of the study, the specificity of the branch also affects the low percentage of infections: the vast majority of treatments are planned, risk factors are taken into account that paying attention to modifiable factors. Perioperative prevention is properly used in the ward.

The incidence at the SSI in the Orthopedics and Traumatology Department of the Movement Organ in the period from January 2022 to December 2022 at 1.37% may be associated with compliance with procedures, but such a low percentage of infections may also indicate underestimation. Studies have shown that in order to increase SSI detection after orthopedic procedures, patients should be monitored after discharge from the hospital. The activity of the hospital clinic guarantees comprehensive care before and after surgery and allows you to monitor the occurrence of SSI.

Conclusions