Infection Control & Hospital Epidemiology Table 2. Procedure Categories by Surgical Facility Typea Surgical Facility Hospital-Based Procedure Type


Soft-tissue excision Hernia


Scrotal/testicular Arthroscopy Eye


Penile Reconstruction ENT, excision Tympanoplasty


Hardware adjustment/removal Orthopedics, hand/foot Tendon repair Ptosis repair Frenulectomy Eye, excision


Cochlear Implant Bone Excision Skin/tissue graft


Facial reconstruction Lysis


ENT, other Scar revision


Perianal excision Gastrointestinal


No.


706 720 419 399 417 353 218 174 257 190 153 145 87


125 115 117 108 104 53 57 54 24 22


(%)


(13) (13) (8) (7) (8) (6) (4) (3) (5) (3) (3) (3) (2) (2) (2) (2) (2) (2) (1) (1) (1) (0) (0)


No. 827 577 306 267 198 252 136 127 24 25 28 26 82 29 15 11 15 16 54 30 20 16 11


ASF


(%) (27) (19) (10) (9) (7) (8) (4) (4) (1) (1) (1) (1) (3) (1) (0) (0) (0) (1) (2) (1) (1) (1) (0)


No.


1,533 1,297 725 666 615 605 354 301 281 215 181 171 169 154 130 128 123 120 107 87 74 40 33


Overall


(%) (18) (15) (9) (8) (7) (7) (4) (4) (3) (3) (2) (2) (2) (2) (2) (2) (1) (1) (1) (1) (1) (0) (0)


No. 77 32 22 28 43 38 13 25 16 18 7


15 3 7 9


10 8 7 1 2 5 4 6


Evidence of Possible Infectionb


Rate, No. per 1,000 Encounters 50 25 30 42 70 63 37 83 57 84 39 88 18 45 69 78 65 58 9


23 68


100 182


Note. ASF, ambulatory surgical facility; ENT, ear, nose and throat. aPercentages sum to >100% because multiple procedure categories could be performed in a single surgical encounter. Table is restricted to the 23 procedure categories (n=7,747) that


occurred >10 times at both facility types in the cohort, sorted in descending order of overall number of procedures. bExpanded definition, cases with strong or some evidence. Cases may have been counted twice if the surgical encounter included multiple procedure categories.


ambulatory procedures. Using a more liberal SSI definition, Owens et al12 found a 30-day rate of “clinically significant SSI” of 4.84 SSIs per 1,000 surgical encounters among adults undergoing ambulatory surgery. Our data suggest that rates of infection following pediatric surgery might be lower than that reported in adults, particularly when strict surveillance definitions are applied. Recognizing that definitions used for surveillance can fail to


capture all infections after a healthcare encounter, we also applied a more permissive definition of possible infections after sur- gery.13,14 This definition captured information from parental interviews as well as data readily available from the EHR suggestive of postoperative infection. This expanded definition revealed a substantially higher infection rate, which is not surprising given the limitations of strict application of NHSH criteria. For example, cellulitis at the surgical site does not meet


NHSN criteria for SSI but was identified by this expanded defi- nition. Efforts to prevent SSI might benefit from incorporation of such clinical presentations, particularly since they can lead to unscheduled patient encounters, procedures, and/or antibiotic prescriptions, all of which indicate resource utilization and potential patient harm. Determining the optimal definitions and surveillance strategies will require future work that considers the need for objective surveillance criteria with comprehensive cap- ture of infectious events, which are not always well documented. While the incidences of both NHSN-defined SSI and possible


infection associated with surgery were low, the volume of ambulatory surgeries suggests that the cumulative burden experienced by patients, families, and clinicians is substantial. An estimated 2.9 million pediatric (<15 years old) ambulatory surgical procedures were per- formed in 2010,4 and we estimate that the annual burden of pediatric


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