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Patient-Reported Wound Symptoms and Patient-Provider Agreement on SSI

Authors:

Abstract

Background: Surgical site infections (SSIs) are a common and costly post-surgical problem, contributing to significant morbidity, mortality, and increased cost of care. Because post-surgical stays have shortened, most SSIs now manifest after hospital discharge. Hypothesis: While patients may report symptoms consistent with wound infection, patient assessment of symptoms will be of limited use in diagnosing SSIs. Methods: We conducted a pilot observational study of post-surgical patients prospectively surveyed for wound symptoms at time of discharge, 3-days post-discharge (PD), at post-operative clinic follow-up (POCV), and at 30-days PD. At POCV, care providers were surveyed on signs of SSI, as well as the diagnosis of SSI. Patients who were diagnosed by their surgical team, had their wound opened, had positive cultures, and/or were provided antibiotics by their surgical team were considered to have SSIs. Results: Between 23 and 28 patients completed surveys at the various time points. 57% of patients reported at least one symptom at time of discharge, 46% and 48% reported symptoms at 3-days and follow-up visit respectively, and 36% reported symptoms at 30-days post-discharge. Concordance between patient and provider assessments on signs and symptoms ranged from 57-100% (mean 83%) The two patient reported symptoms found among those with provider diagnosed SSI were wound discharge and separation, with one patient reporting each. Three patients self-reported having a SSI. Two patients were diagnosed by providers as having SSIs. Overall concordance about the presence or absence of SSI at POCV was 79%, but PPV of patients self-diagnosing SSI was 33%, and the inter-rater agreement between providers and patients when patients thought they had an SSI was very low (κ=0.125). Conclusions: There was significant discrepancy between patient and provider diagnosis of SSI, and no specific symptoms, or combination of symptoms accurately diagnosed SSI. The high gross correlation observed represented patients and provider agreement when no signs and symptoms and/or no SSI was present. Correlation between patient-diagnosed wound problems and provider assessment was no better than chance, and this highlights the need for better tools to enable objective assessment of wound healing by the surgical team, in addition to patient-reported symptoms, in order to allow earlier diagnosis of SSI and minimize emergency room visits and preventable readmissions. Future work will include analysis of clinical outcomes at 30 days post-discharge.
Patient-Reported Wound Symptoms
and Patient-Provider Agreement on SSI
Timo Hakkarainen1, Patrick Sanger2, Cheryl Armstrong1, Andrea Hartzler3, and Heather Evans1
University of Washington Departments of Surgery1and Biomedical Health Informatics and Medical Education2,
GroupHealth Research Institute3
Funded by the Institute for Translational Health Research Small Pilot Award, University of Washington and the
Surgical Infection Society Foundation Junior Faculty Fellowship Award.
Surgical site infections (SSIs) are the most common HAI after surgery, greatest
overall contributor to HAI cost
Progressively shorter length of post-surgical stay has resulted in most SSIs
manifesting after hospital discharge
Standard post-operative visits occur after the period at greatest risk of
developing SSI (5-7 days post-discharge)
SSI associated with high rate of readmission, morbidity
No standardized, active post-discharge surveillance tools for surgical provider to
detect SSI in evolution
Introduction
Sanger PC, Hartzler A, Han SM, Armstrong CAL, Stewart MR, Lordon RJ, et al. Patient perspectives on post-discharge surgical site infections:
towards a patient-centered mobile health solution. PLoSONE. 2014;9(12):e114016.
To characterize the post-discharge experience
of patients following abdominal surgery with
particular attention to wound symptoms and
infectious complications
Purpose
Study Design and Methods
Prospective pilot observational study
All surveys were completed electronically using DatStat platform
Electronic medical record review performed after surveys completed
Descriptive statistics performed on subset of patients who completed at least 2
survey time points
Survey Time Point
Patients Providers
Discharge
X X
3
-days post-discharge X
Post
-op follow up visit X X
30
-days post-discharge X
Results
Participant Characteristics
Age (years,
s.d.)
50.4
± 15.7
Sex: Female
20 (50%)
Race
White
34 (85%)
Asian
3 (7.5%)
African American
1 (2.5%)
Native American
1 (2.5%)
unspecified
1 (2.5%)
Smoker
never
24 (66.7)
former
10 (27.8)
current
2 (5.6)
Diabetes
6 (15%)
Prior laparotomy
22 (55%)
Operative data
Operation
20 (50%)
7 (17.5%)
11 (27.5%)
1 (2.5%)
1 (2.5%)
Approach
-assisted
6 (15%)
1 (2.5%)
33 (82.5%)
Surgery type: elective
38 (95%)
Surgery duration (min, s.d)
275.8
± 149.2
Results
Outcomes (n=40)
Length of Stay (days, s.d)
5.9
± 2.3
Post
-operative in-hospital infection
2 (5%)
Post
-discharge infection
10 (25%)
Kept follow up appt
36 (90%)
Days to follow up appointment
14.2
± 8
Readmission or ED visit
12 (30%)
Results
Survey Time Point (n)
Discharge
(28)
3 days
(34)
Post
-op visit
(37)
30 days
(40)
Patient reported wound symptom
17 (61%) 12 (50%) 18 (49%) 11 (28%)
“Seen a doctor”
- 6 (18%) 23 (62%) 36 (90%)
ED
visit or hospital readmission - 1 (3%) 5 (14%) 9 (23%)
Provider reported
SSI
(
EMR review at 30d)
0 0 2 (5%) 3 (7%)
Patient reported
SSI
“yes” - 0 1 (3%) 0
“don’t know” - 1 (3%) 1 (3%) 2 (5%)
“prescribed
antibiotic for
wound”
- 1 (3%) 2 (5%) 3 (8%)
Conclusions
Significant discrepancy between patient and provider diagnosis of
SSI
Patients not aware of SSI diagnosis even when treated
High rate of healthcare utilization prior to post-operative follow-
up visit
Opportunity to develop post-discharge tools to enable
objective serial assessment of wounds for SSI
optimization of post-operative care visits
Patient-Reported Wound Symptoms
and Patient-Provider Agreement on SSI
Timo Hakkarainen1, Patrick Sanger2, Cheryl Armstrong1, Andrea Hartzler3, and Heather Evans1
University of Washington Departments of Surgery1and Biomedical Health Informatics and Medical Education2,
GroupHealth Research Institute3
Funded by the Institute for Translational Health Research Small Pilot Award, University of Washington and the
Surgical Infection Society Foundation Junior Faculty Fellowship Award.
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