择期手术推迟施行与术后感染风险增加相关

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择期手术推迟施行与术后感染风险增加相关
Delayed Elective Surgery Linked to Increased Postoperative Infections

Elsevier Global Medical News

拉斯维加斯(EGMN)——一项涉及163,000例美国患者的回顾性研究表明，择期手术患者术前住院时间越长，术后出现感染的风险便越大。

在美国外科感染协会2010年年会上，Todd R. Vogel博士报告称，择期手术患者哪怕是在术前1天入院，与在手术当天入院的患者相比，术后出现感染的风险都会显著增加20%~50%。

美国新泽西州新伯朗士威Robert Wood Johnson医学院的血管外科医生Vogel博士说，对于术前住院6~10天的患者，风险还会增加2倍以上。

Vogel博士在采访中说：“显然，一些潜在的管理问题导致了手术的延期。”较之接受肺或结肠切除术的患者，在接受冠状动脉旁路移植术(CABG)的患者中手术延期的情况更为普遍。

Vogel博士补充道，研究数据表明，最好是让患者先回家等到手术当天再入院，而不是令其在轮到他们手术之前一直在医院呆上好几天。

会上，其他外科医生提出了另一种解释，即许多被推迟施行的手术事实上不属于择期手术。

美国克立夫兰MetroHealth 医学中心的外科医生Jeffrey A. Claridge博士问道：“现如今，有哪家医院会在收治了患者之后等到第二天才对其施行结肠切除术？”

美国西雅图华盛顿大学教授兼普外科主任E. Patchen Dellinger博士说：“我认为手术之所以被推迟肯定与医院的管理制度有关。”

但Vogel博士怀疑这些被推迟的病例实际上并不全是真正意义上的择期手术患者。Vogel博士指出，医院可能会把不属于择期手术的病例视为可以择期手术，以此来增加收入。

Vogel博士及其同事采用的是全美住院患者样本于2003~2007年收集到的数据，该数据库收录了美国38个州出院患者的信息，由医疗成本与效用项目负责维护。研究者纳入了年龄≥40岁且为了接受以下3种类型的手术之一而入院的患者：87,318例接受的是CABG，46,728例接受的是结肠切除术，28,960例则接受肺切除术。几乎1/3的患者都属于60~69岁年龄段，另外接近1/3的患者属于70~79岁年龄段，还有20%介于50~59岁。几乎2/3的患者都是男性，白种人占84%，非洲裔美国人占6%，西班牙裔人占5%。择期手术在入院后10天以上才施行者被排除在分析之外。

所分析的感染并发症包括肺炎、尿路感染、败血症和手术部位感染。

接受CABG的患者入院后手术推迟施行的发生率最高，仅53%在入院当天接受了手术，而在接受结肠切除术和肺切除术的患者中分别有79%和94%在入院当天就接受了手术。在接受CABG的患者中，另有23%手术被推迟了1天，21%推迟了2~5天，3%则在入院后6~10天才接受手术。在接受结肠切除术的患者中，13%推迟了1天，7%推迟了2~5天，2%推迟了6~10天(由于四舍五入所以加起来是101%)。而在接受肺切除术的患者中，3%等了1天，2%等了2~5天，1%等了6~10天。

对于入院当天就接受了手术的患者，CABG、肺切除和结肠切除组术后感染的发生率分别为5.7%、8.4%和10.2%。推迟的时间越长，感染的发生率就越高。对于入院后6~10天才接受手术的患者，CABG、肺切除和结肠切除组术后感染的发生率分别为18.2%、21.6%和20.6%。

在CABG和结肠切除组中，尿路感染是最常见的感染类型，其次是肺炎。在肺切除组中，肺炎则最为常见。

对年龄、性别、种族和合并症进行校正后的多因素分析显示，较之手术没有被推迟施行的患者，研究所划分的3个延期时段均导致了所有3种手术组感染的发生率显著增加。
Vogel博士说，分析还进一步表明，在患者入院后推迟施行手术与住院费增加相关。在手术没有被推迟的患者中，CABG、肺切除和结肠切除组的平均住院费分别为25,164、18,519和13,660美元。在仅推迟了1天的患者中，平均住院费分别为28,962、22,169和17,431美元。Vogel博士说，推迟时间越长，平均住院费用就越高。

Vogel博士声明无相关利益冲突。

潮水

原文
LAS VEGAS (EGMN) –The longer elective-surgery patients were hospitalized before their operation, the greater their risk of developing an infection postoperatively, according to a review of 163,000 U.S. patients.

Elective-admission patients hospitalized for just 1 day before their surgery had a significant 20%-50% increased risk of subsequent infection, compared with patients whose surgery took place the same day as their hospital admission, Dr. Todd R. Vogel reported at the annual meeting of the Surgical Infection Society.

Patients hospitalized for 6-10 days before surgery had a greater than twofold increased risk, said Dr. Vogel, a vascular surgeon at the Robert Wood Johnson Medical School, New Brunswick, New Jersey.

“Obviously there is some underlying management issue that is causing the delay,” and delays were much more frequent among patients having coronary artery bypass grafting (CABG) than among those who had either lung or colon resection. “As patients spend more days in the hospital, they face more risk of picking up an infection,” Dr. Vogel said in an interview.

The data suggest that it would be better to send patients home to await the day of their planned surgery than to keep them in the hospital for a few days until their slot on the schedule opens, he added.

Other surgeons at the meeting suggested that another possible explanation is that many of the delayed cases weren’t really elective.

“In this day and age, what hospital would admit a patient and then wait until the next day to take out their colon?” asked Dr. Jeffrey A. Claridge, a surgeon at MetroHealth Medical Center, Cleveland.

“I think there were reasons for the delay that you can’t pick out of your administrative database,” said Dr. E. Patchen Dellinger, professor and chief of the division of general surgery at the University of Washington, Seattle.

But Dr. Vogel expressed skepticism that these weren’t virtually all truly elective patients. Hospitals would want to “upcode” cases that were not elective because they would be paid more, he noted.

He and his associates used data collected during 2003-2007 in the Nationwide Inpatient Sample, a database of hospital discharges in 38 states maintained by the Healthcare Cost and Utilization Project. They focused on patients aged 40 years or older who had elective admissions for any of three types of surgery: 87,318 who underwent CABG, 46,728 who had colon resection, and 28,960 who underwent lung resection. Almost a third of the patients were aged 60-69 years, nearly another third were 70-79 years old, and 20% were aged 50-59 years. Nearly two-thirds were men, and 84% were white, 6% African American, and 5% Hispanic. The analysis excluded patients who had had surgery more than 10 days after their elective hospital admission.

The infectious complications analyzed included pneumonia, urinary tract infection, sepsis, and surgical site infections.

Patients undergoing CABG had the highest rate of delays between admission and surgery, with 53% having their surgery on the same day of admission, compared with 79% of colon resection patients and 94% of lung resection patients. Another 23% of the CABG patients had a 1-day delay, 21% had a 2-5 day delay, and 3% had their surgery 6-10 days after admission. In the colon resection group, 13% had a 1-day delay, 7% waited 2-5 days, and 2% had a delay of 6-10 days (total is 101% because of rounding). Among those having lung resection, 3% waited 1 day, 2% waited 2-5 days, and 1% waited 6-10 days.

The postsurgical infection rate for patients who had their surgery on the day they were admitted reached 5.7% in the CABG patients, 8.4% in the lung resection patients, and 10.2% in the colon resection patients. The rates increased for each incremental delay. Among patients whose surgery was performed 6-10 days after admission, postsurgical infection rates were 18.2% for CABG, 21.6% for lung resection, and 20.6% for colon resection.

In the CABG and colon resection groups, urinary tract infection was the most common type of infection, followed by pneumonia. In the lung resection patients, pneumonia topped the infection list.

Multivariate analysis that adjusted for age, gender, race, and comorbidities showed that all three delay durations categorized in the study led to significantly greater infection rates relative to patients who had no delay in surgery, for all three operations analyzed (see chart).

Analysis further documented that in-hospital delays before surgery were linked to higher hospital costs. Among patients with no delay in surgery, average hospital costs reached (USD) $25,164, $18,519, and $13,660 for CABG, lung, and colon surgery, respectively. In patients with just a 1-day delay, costs averaged (USD) $28,962, $22,169, and $17,431, respectively. Longer delays were associated with even higher average hospital costs, Dr. Vogel said.

Dr. Vogel reported no disclosures.

niujialan

回复 2# 潮水
您真有才啊,手术之所以被推迟肯定与医院的管理制度有关,并且增加了感染的机会.....学习了,谢谢!

沧海一粟

回复 1# 潮水
有统计证明，住院时间越长，感染发病率越高。也印证了上面的结论。

清丽幽妙

"择期手术患者术前住院时间越长，术后出现感染的风险便越大"
认同这种观点！

桂花香

手术前住院时间延长可增加手术感染的发生。
但是在我们这里，入院当天或入院后2-3天手术的病人不算多！对于一些需要进行CT或MRI等大型检查的病人，往往还要等候更长的时间。

小雨点儿

那就让择期手术的病人完善应该做的辅助检查再住院?还是医生加班加点的把手术做了？

清清

回复 1# 潮水

学习了，谢谢！我国也和其他国家一样推行临床路径了，执行临床路径后，术前无效住院日、平均住院日也缩短，择期手术今后就不会无故推迟手术了，术后感染的也可能会少一些。