Infection Control & Hospital Epidemiology
enrolled, and interviewed by telephone (Fig. 2). Of these 8,502 surgical encounters, manual EHR reviews were completed for 1,259 patients (15%), including 634 cases triggered by potential postsurgical complications reported in parental interviews and an additional 625 records triggered by antibiotic prescriptions and/or ED visits or hospitalizations documented in the EHR (data electronically extracted). The enrolled cohort and the cohort of eligible surgical encounters were demographically similar (Supplementary Table 1). Overall, 5,467 (64%) of the surgical encounters in the enrolled
cohort occurred at the hospital-based facility. Children who underwent surgery at the hospital-based facility were more likely to be of black race, to use public insurance, and to have >1 procedure performed during the surgical encounter (Table 1). Also, the distribution of surgical encounters by surgical specialty differed between the facility types. Only 23 procedure categories were performed >10 times at the ASFs and only 3 categories (soft tissue excision, hernia, scrotal/testicular) accounted for 56% of enrolled surgical encounters at the ASFs (Table 2). Overall, 16 procedure categories performed only at the hospital- based facility; the top 3 were surgery involving teeth (n=131), oral/maxillofacial surgery (n=75), and cataract extraction (n=57).
NHSN SSIs
We identified 21 SSIs that met NHSN criteria for an overall SSI rate of 2.5 SSIs per 1,000 surgical encounters: 2.9 SSIs per 1,000
153
surgical encounters at the hospital-based facility and 1.6 SSIs per 1,000 surgical encounters at the ASFs. In the restricted cohort of procedures routinely performed
at both facility types (n=7,747), unadjusted NHSN SSI rates were similar to the full cohort (overall rate, 2.5 SSIs per 1,000 surgical encounters; hospital-based facility rate, 3.0 SSIs per 1,000 surgical encounters; ASF rate, 1.7 SSIs per 1,000 surgical encounters). The adjusted conditional analysis of this restricted cohort (adjusted for age and number of procedures conditioned on procedure category) revealed no difference in the NHSN SSI rate between the hospital-based facility and the ASFs (OR, 0.7; 95% CI, 0.20–2.3).
Expanded definition of possible infection associated with surgery
Based on parental interviews, 306 cases were identified with evidence of possible infection, including 119 cases with strong evidence and 187 with some evidence. Based on data from the EHR manual case reviews, 228 cases had evidence of possible infection, including 154 cases with strong evidence and 74 with some evidence. Of 228 cases, 204 cases (89.5%) documented in the EHR occurred within 30 days of surgery. Combining both data sources, we identified 404 surgical encounters with strong or some evidence of possible infection that would warrant investi- gation from the infection prevention and control staff (rate, 48 SSIs per 1,000 surgical encounters). At the hospital-based facility, the unadjusted rate was 51 SSIs per 1,000 surgical encounters (279 cases), and at the ASF, the rate was 41 SSIs per 1,000 (125 cases). Table 2 lists the rate by procedure category. When we compared case identification by data source (par-
ental interview and EHR) within the 30 days after surgery, there was poor agreement: Of the 306 cases with evidence of possible infection associated with surgery reported in the parental inter- view, 176 (57%) did not meet the definition for some or strong evidence based on documentation in the EHR (Supplementary Table 2). Of 204 cases with evidence of possible infection asso- ciated with surgery documented in the EHR, 74 (36%) were not supported by evidence reported in the parental interview.
Risk factors for evidence of possible infection associated with surgery
Using our expanded definition in the restricted cohort (n=7,747), there were 367 (4.7%) surgical encounters with evi- dence of possible infection. In univariate analysis conditioned on the procedure category, both older age and black race were associated with reduced risk of evidence of infection related to surgery (Table 3). In multivariable analysis, these associations remained statistically significant. Multivariable analysis was replicated only using cases identified from the interviews, and the results for race were consistent (black race: OR, 0.62; 95% CI, 0.42–0.93).
Discussion Fig. 2. Assembly of study cohort. Note. EHR, electronic health record.
Utilizing a large, integrated, pediatric healthcare network in the United States, we prospectively defined the incidence of and risk factors for infections after ambulatory surgery in children. While the estimated incidence of SSI after pediatric ambulatory surgery was 2.5 SSIs per 1000 surgical encounters using NHSN defini- tions, an expanded definition using parental report and EHR
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