Reduction of Surgical Site Infections after Implementation of a Bundle of Care

BACKGROUND: Surgical Site Infections (SSI) are relatively frequent complications after colorectal surgery and are associated with substantial morbidity and mortality. OBJECTIVE: Implementing a bundle of care and measuring the effects on the SSI rate. DESIGN: Prospective quasi experimental cohort study. METHODS: A prospective surveillance for SSI after colorectal surgery was performed in the Amphia Hospital, Breda, from January 1, 2008 until January 1, 2012. As part of a National patient safety initiative, a bundle of care consisting of 4 elements covering the surgical process was introduced in 2009. The elements of the bundle were perioperative antibiotic prophylaxis, hair removal before surgery, perioperative normothermia and discipline in the operating room. Bundle compliance was measured every 3 months in a random sample of surgical procedures. RESULTS: Bundle compliance improved significantly from an average of 10% in 2009 to 60% in 2011. 1537 colorectal procedures were performed during the study period and 300 SSI (19.5%) occurred. SSI were associated with a prolonged length of stay (mean additional length of stay 18 days) and a significantly higher 6 months mortality (Adjusted OR: 2.71, 95% confidence interval 1.76-4.18). Logistic regression showed a significant decrease of the SSI rate that paralleled the introduction of the bundle. The adjusted Odds ratio of the SSI rate was 36% lower in 2011 compared to 2008. CONCLUSION: The implementation of the bundle was associated with improved compliance over time and a 36% reduction of the SSI rate after adjustment for confounders. This makes the bundle an important tool to improve patient safety

Annual changes in the surgical site infection (SSI) rate and bundle compliance and the 95% confidence interval.

<p>Footnote: 2008 was taken as the reference year for SSI and the relative changes after adjustment for confounding variables are provided.</p

Continuous variables in relation to the occurrence of surgical site infections (SSI) after colorectal surgery.

<p>Continuous variables in relation to the occurrence of surgical site infections (SSI) after colorectal surgery.</p

Kaplan meier curve of 6 months mortality in patients with and without a surgical site infection (SSI).

<p>Kaplan meier curve of 6 months mortality in patients with and without a surgical site infection (SSI).</p

Categorical variables in relation to the occurrence of surgical site infections (SSI) after colorectal surgery.

<p>ASA class: American Society of Anesthesiologists classification.</p><p>Wound class: Classification based on the intrinsic contamination of the incision site.</p

Compliance with the bundle and its individual components in repeated measurements from June 2009 through October 2011.

<p>Compliance with the bundle and its individual components in repeated measurements from June 2009 through October 2011.</p

Genome-wide association study of borderline personality disorder reveals genetic overlap with bipolar disorder, major depression and schizophrenia

Borderline personality disorder (BOR) is determined by environmental and genetic factors, and characterized by affective instability and impulsivity, diagnostic symptoms also observed in manic phases of bipolar disorder (BIP). Up to 20% of BIP patients show comorbidity with BOR. This report describes the first case–control genome-wide association study (GWAS) of BOR, performed in one of the largest BOR patient samples worldwide. The focus of our analysis was (i) to detect genes and gene sets involved in BOR and (ii) to investigate the genetic overlap with BIP. As there is considerable genetic overlap between BIP, major depression (MDD) and schizophrenia (SCZ) and a high comorbidity of BOR and MDD, we also analyzed the genetic overlap of BOR with SCZ and MDD. GWAS, gene-based tests and gene-set analyses were performed in 998 BOR patients and 1545 controls. Linkage disequilibrium score regression was used to detect the genetic overlap between BOR and these disorders. Single marker analysis revealed no significant association after correction for multiple testing. Gene-based analysis yielded two significant genes: DPYD (P=4.42 × 10^−7) and PKP4 (P=8.67 × 10^−7); and gene-set analysis yielded a significant finding for exocytosis (GO:0006887, P_FDR=0.019; FDR, false discovery rate). Prior studies have implicated DPYD, PKP4 and exocytosis in BIP and SCZ. The most notable finding of the present study was the genetic overlap of BOR with BIP (r_g=0.28 [P=2.99 × 10^−3]), SCZ (r_g=0.34 [P=4.37 × 10^−5]) and MDD (r_g=0.57 [P=1.04 × 10^−3]). We believe our study is the first to demonstrate that BOR overlaps with BIP, MDD and SCZ on the genetic level. Whether this is confined to transdiagnostic clinical symptoms should be examined in future studies