Length of preoperative hospital stay: a risk factor for reducing surgical infection in femoral fracture cases

Pereira, Hoberdan Oliveira; Rezende, Edna Maria; Couto, Bráulio Roberto Gonçalves Marinho

doi:10.1016/j.rboe.2015.09.006

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ORIGINAL ARTICLE • Rev. bras. ortop. 50 (6) • Nov-Dec 2015 • https://doi.org/10.1016/j.rboe.2015.09.006 copy

Length of preoperative hospital stay: a risk factor for reducing surgical infection in femoral fracture cases

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE:

To analyze infections of the surgical site among patients undergoing clean-wound surgery for correction of femoral fractures.

METHODS:

This was a historical cohort study developed in a large-sized hospital in Belo Horizonte. Data covering the period from July 2007 to July 2009 were gathered from the records in electronic medical files, relating to the characteristics of the patients, surgical procedures and surgical infections. The risk factors for infection were identified by means of statistical tests on bilateral hypotheses, taking the significance level to be 5%. Continuous variables were evaluated using Student'sttest. Categorical variables were evaluated using the chi-square test, or Fisher's exact test, when necessary. For each factor under analysis, a point estimate and the 95% confidence interval for the relative risk were obtained. In the final stage of the study, multivariate logistic regression analysis was performed.

RESULTS:

432 patients who underwent clean-wound surgery for correcting femoral fractures were included in this study. The rate of incidence of surgical site infections was 4.9% and the risk factors identified were the presence of stroke (odds ratio, OR = 5.0) and length of preoperative hospital stay greater than four days (OR = 3.3).

CONCLUSION:

To prevent surgical site infections in operations for treating femoral fractures, measures involving assessment of patients' clinical conditions by a multiprofessional team, reduction of the length of preoperative hospital stay and prevention of complications resulting from infections will be necessary.

Keywords:
Infection of the operative wound; Femoral fractures; Risk factors

Variable	Frequency	%	Mean	Median	Minimum	Maximum	SD
Sex
Female	208	48.1
Male	224	51.9
Age (years)			57	66	4	102	27.3

Age (years)
<20	55	12.7
20–39	80	18.5
40–59	55	12.7
60–79	122	28.2
≥80	120	27.8
Length of hospital stay (days)			14	8	1	139	19.4
Length of hospital stay before surgery (days)			8	5	0	234	14.1

Length of hospital stay before surgery (days)
Up to 4	185	42.8
More than 4	247	57.2
Duration of surgery (h)			1:50	1:40	0:10	8:20	1:01

Duration of surgery (min)
Up to 138	320	74.1
More than 138	112	25.9

ASA – American Society of Anesthesiology (score)
I	174	42.8
II	156	38.3
III	70	17.2
IV	7	1.7

Type of surgery
Elective	373	86.3
Emergency	59	13.7

Time of day of the surgery
Morning	216	50
Afternoon	195	45.1
Night	21	4.9

Type of osteosynthesis
Plate	224	52.2
Nail	105	24.5
Screw	51	11.9
Other	27	6.3
Cement	22	5.1

Variable	Total number of patients	Total number of cases with SSI	Risk of SSI (%)	Relative risk	95% CI	p value
Length of hospital stay before surgery (days)
Up to 4	185	4	2.2
More than 4	247	17	6.9	3.2	[1.09–9.30]	0.018

Stroke
Yes	22	4	18.2	4.4	[1.61–11.93]	0.017
No	410	17	4.1

Sex
Female	208	14	6.7	2.2	[0.89–5.23]	0.064
Male	224	7	3.1

Type of trauma (ICD-10)
V87	29	2	6.9	1	–	0.734
W01	230	12	5.2	0.8	[0.31–5.61]
W06.0	14	1	7.1	1	[0.10–9.77]
W10	11	0	0.0	0.	–
Y30	20	2	10.0	1.5	[0.11–4.50]
V23	67	3	4.5	0.6	[0.27–8.73]
Other	61	1	1.6	0.2	[0.40–44.53]

Fracture classification
Tronzo	150	4	2.7	1	–	0.475
Garden	105	7	6.7	2.5	[0.12–1.33]
AO	100	7	7	2.6	[0.11–1.27]
Seinsheimer	32	1	3.1	1.2	[0.10–7.38]
Other	45	2	4.4	1.7	[0.11–3.17]

Duration of the operation (min)
Up to 138	320	13	4.1	0.6	[0.24–1.34]	0.147
More than 138	112	8	7.1

ASA
I	174	6	3.4	1	–	0.169
II	156	12	7.7	2.2	[0.17–1.17]
III	70	2	2.9	0.8	[0.25–5.84]
IV	7	1	14.3	4.1	[0.03–1.74]

Type of surgery
Elective	373	20	5.4	3.2	[0.43–23.13]	0.191
Emergency	59	1	1.7

Time of day of the surgery
Morning	216	9	4.2	1	–	0.367
Afternoon	195	12	6.2	1.5	[0.29–1.57]
Night	21	0	0	0	–

Diabetes mellitus (DM)
Yes	26	2	7.7	1.6	[0.40–6.68]	0.365
No	406	19	4.7

Congestive heart failure
Yes	9	0	0	0	–	0.635
No	423	21	5

Cardiopathy
Yes	16	0	0	0	–	0.444
No	416	21	5

Hypertension
Yes	148	9	6.1	1.4	[0.62–3.34]	0.264
No	284	12	4.2

Chronic obstructive pulmonary disease (COPD)
Yes	8	0	0	0	–	0.668
No	424	21	5

Hypercholesterolemia
Yes	3	0	0	0	–	0.860
No	429	21	4.9

Alcohol abuse
Yes	19	1	5.3	1.1	[0.15–7.68]	0.620
No	413	20	4.8

Psychiatric disorders
Yes	18	1	5.6	1.2	[0.16–8.10]	0.599
No	414	20	4.8

Metabolic disorders
Yes	9	0	0	0	–	0.635
No	423	21	5

Cancer
Yes	12	0	0	0	–	0.545
No	420	21	5

Type of osteosynthesis
Plate	224	15	6.7	1	–	0.246
Nail	105	2	1.9	0.3	[0.82–15.09]
Screw	51	1	2	0.3	[0.46–25.27]
Other	27	1	3.7	0.6	[0.03–8.14]
Cement	22	2	9.1	1.4	[0.04–4.20]

Anesthesia: spinal anesthesia with sedation
Yes	224	14	6.3	1.9	[0.76–4.71]	0.120
No	208	7	3.4

Surgical infection risk index
Score 0	246	11	4.5	0.7	[0.31–1.66]	0.585
Score up to 2	161	10	6.2

Anemia
Yes	178	10	5.6	1.4	[0.59–3.43]	0.288
No	228	9	3.9

Hematocrit less than 36mg/dL
Yes	259	15	5.8	2.1	[0.72–6.29]	0.120
No	147	4	2.7

Skin colonization
Yes	17	1	5.9	1.2	[0.17–8.57]	0.578
No	415	20	4.8

General anesthesia
Yes	41	2	4.9	1	[0.24–4.16]	0.620
No	391	19	4.9

Variable	SSI	Number of patients	Mean	Median	Standard deviation	p value
Length of hospital stay before operation (days)	Yes	9	31	21	24.9	0.008
	No	193	13	8	18.8
Age (years)	Yes	21	63	73	27.5	0.329
	No	411	57	66	27.3
Duration of operation (h)	Yes	21	2:14	1:44	0.1	0.365
	No	411	1:49	1:39	0
Hemoglobin	Yes	19	11.0	10.6	1.2	0.298
	No	387	11.4	11.3	2
Hematocrit	Yes	19	33.0	32.5	4.1	0.323
	No	387	34.3	33.9	6
Glycemia	Yes	11	122.2	106.0	34.7	0.913
	No	167	126.9	114.0	62

Variable	Regression coefficient	Standard error of the regression coefficient	Odds ratio	p value
Preoperative length of hospital stay greater than 4 days	1.19	0.57	3.3	0.037
Stroke	1.60	0.62	5	0.009
Constant	-3.96	0.52

Type of patient	Expected risk of SSI (%)	Number of patients	Observed SSI	Observed risk of SSI (%)
No stroke and length of stay up to 4 days	1.9	177	2	1.1
No stroke and length of stay more than 4 days	5.9	233	15	6.4
Previous stroke and length of stay up to four days^a	8.6	8	–	–
Previous stroke and length of stay more than four days^a	23.6	14	–	–

SSI	Number of patients	Hospital mortality	Risk of hospital death (%)	Relative risk	95% confidence interval	p value
Yes	21	3	14.3	2.6	[0.83–7.83]	0.125
No	411	23	5.6
Total	432	26	6

Variable	Frequency	%
Etiological agent identified for SSI
Yes	11	52
No	10	48
Total	21	100

Etiological agent for SSI
Acinetobacter baumannii	2	18
Staphylococcus aureus	2	18
Enterobacter cloacae+Acinetobacter baumannii	1	9
Enterococcus sp.	1	9
Escherichia coli+Acinetobacter baumannii	1	9
Escherichia coli+Enterococcus sp. (ESBL-producing)	1	9
Proteus mirabilis	1	9
Proteus mirabilis+MRSA	1	9
Staphylococcus aureus+Enterococcus sp.	1	9
Total	11	100

Skin colonization?
Yes	9	2
No	423	98
Total	432	100

Skin microorganisms identified
Staphylococcus aureus	5	55.0
Staphylococcus aureus+Enterobacter sp.	2	22.0
Proteus mirabilis	1	11.0
Staphylococcus aureus+Streptococcus pyogenes	1	11.0
Total	9	100.0

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E-mail: rbo@sbot.org.br

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[1] * Corresponding author. E-mail:hoberdanoliveira2013@gmail.com(H.O. Pereira).