NSG 6330 Discussions and Prophylactic Hysterectomy review

NSG 6330 Discussions and Prophylactic Hysterectomy review

NSG 6330 Discussions and Prophylactic Hysterectomy review

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NSG 6330 Discussions and Prophylactic Hysterectomy review Week 1 Discussion

Preventative Screening

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will review the latest evidence based guidelines as they pertain to the case below .Discussion of the case is based on the course objectives and weekly content, which emphasize the core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, case study discussions are used to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

Janice, a 21 year-old healthy female, presents to her nurse practitioner for her yearly check-up .She is sexually active with her boyfriend and uses condoms most of the time .She has never had a pelvic exam before .

Discuss the recommended screening tests, using the latest evidence based guidelines that the nurse practitioner should perform on Janice .

Discuss the recommended education and counseling that should be included in Janice’s care?

NSG 6330 Week 2 Discussion iHuman Case Study Angela Cortez

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This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will complete an iHuman case study based on the course objectives and weekly content .The iHuman cases emphasize core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, you will use the iHuman case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

The iHuman assignments are highly interactive and a dynamic way to enhance your learning .Material from the iHuman cases may be present in the quizzes, the midterm exam, and the final exam .

Click here for information on how to access and navigate iHuman .

This week, complete the iHuman case titled ”Angela Cortez” .

After completing your iHuman Case Study, answer the following questions using the latest evidenced based guidelines:

Discuss the questions that would be important to include when interviewing a patient with this issue .

Describe the clinical findings that may be present in a patient with this issue .

Are there any diagnostic studies that should be ordered on this patient? Why?

List the primary diagnosis and three differential diagnoses for this patient .Explain your reasoning for each .

Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups .

NSG 6330 Discussions and Prophylactic Hysterectomy review Week 3 Discussion

Contraceptive Management

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings, supplemental readings, and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will review the latest evidence based guidelines as they pertain to the case below .Discussion of the case is based on the course objectives and weekly content, which emphasize the core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, case study discussions are used to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

Karen, is a 33 year-old G2P2, with a medical history of migraines, for which she takes Imitrex when needed .She has a history of heavy and painful menses each month, lasting approximately 7-8 days .Karen smokes ½ pack of cigarettes per day .Her father has a history of DVT and cardiac disease .Her mother has a history of cervical cancer .Her blood pressure today is 138/76 and her pelvic exam is normal .She is divorced and is sexually active with her new boyfriend .She is currently using condoms for birth control and wants something more reliable .Karen does not desire pregnancy in the near future .

Discuss the contraceptive methods using the latest evidence-based guidelines that Karen would be medically eligible for .

Identify one method that you feel would be most beneficial to Karen and discuss why you selected it .

Are there any methods that you would not recommend for Karen? Why?

NSG 6330 Week 4 Discussion iHuman Case Study Rachael Hardy

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will complete an iHuman case study based on the course objectives and weekly content .The iHuman cases emphasize core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, you will use the iHuman case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

The iHuman assignments are highly interactive and a dynamic way to enhance your learning .Material from the iHuman cases may be present in the quizzes, the midterm exam, and the final exam .

Click here for information on how to access and navigate iHuman .

This week, complete the iHuman case titled ”Rachael Hardy” .

After completing your iHuman Case Study, answer the following questions using the latest evidenced based guidelines:

Discuss the questions that would be important to include when interviewing a patient with this issue .

Describe the clinical findings that may be present in a patient with this issue .

Are there any diagnostic studies that should be ordered on this patient? Why?

List the primary diagnosis and three differential diagnoses for this patient .Explain your reasoning for each .

Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups .

NSG 6330 Discussions and Prophylactic Hysterectomy review Week 5 Discussion

iHuman Case Study Pamela Flowers

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will complete an iHuman case study based on the course objectives and weekly content .The iHuman cases emphasize core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, you will use the iHuman case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

The iHuman assignments are highly interactive and a dynamic way to enhance your learning .Material from the iHuman cases may be present in the quizzes, the midterm exam, and the final exam .

Click here for information on how to access and navigate iHuman .

This week, complete the iHuman case titled “Pamela Flowers” .

After completing your iHuman Case Study, answer the following questions using the latest evidenced based guidelines:

Discuss the questions that would be important to include when interviewing a patient with this issue .

Describe the clinical findings that may be present in a patient with this issue .

Are there any diagnostic studies that should be ordered on this patient? Why?

List the primary diagnosis and three differential diagnoses for this patient .Explain your reasoning for each .

Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups .

NSG 6330 Week 6 Discussion

iHuman Case Study Sonya Phillips

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will complete an iHuman case study based on the course objectives and weekly content .The iHuman cases emphasize core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, you will use the iHuman case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

The iHuman assignments are highly interactive and a dynamic way to enhance your learning .Material from the iHuman cases may be present in the quizzes, the midterm exam, and the final exam .

Click here for information on how to access and navigate iHuman .

This week, complete the iHuman case titled “Sonya Phillips” .

After completing your iHuman Case Study, answer the following questions using the latest evidenced based guidelines:

Discuss the questions that would be important to include when interviewing a patient with this issue .

Describe the clinical findings that may be present in a patient with this issue .

Are there any diagnostic studies that should be ordered on this patient? Why?

List the primary diagnosis and three differential diagnoses for this patient .Explain your reasoning for each .

Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups .

NSG 6330 Discussions and Prophylactic Hysterectomy review Week 7 Discussion

iHuman Case Study Erin Davis

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will complete an iHuman case study based on the course objectives and weekly content .The iHuman cases emphasize core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, you will use the iHuman case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

The iHuman assignments are highly interactive and a dynamic way to enhance your learning .Material from the iHuman cases may be present in the quizzes, the midterm exam, and the final exam .

Click here for information on how to access and navigate iHuman .

This week, complete the iHuman case titled “Erin Davis” .

After completing your iHuman Case Study, answer the following questions using the latest evidenced based guidelines:

Discuss the questions that would be important to include when interviewing a patient with this issue .

Describe the clinical findings that may be present in a patient with this issue .

Are there any diagnostic studies that should be ordered on this patient? Why?

List the primary diagnosis and three differential diagnoses for this patient .Explain your reasoning for each .

Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups .

NSG 6330 Discussions and Prophylactic Hysterectomy review Week 8 Discussion

LGBT Health Care

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will review and reflect on the LGBT article .This article can be applied to healthcare providers in the multiple care settings .Discussion of the article is based on the course objectives and weekly content, which emphasize the core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, discussions are used to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

Discuss any “take-away” thoughts from the article .

How do you plan to make a positive impact on the care of LGBT patients when you become a NP? What attitudes/behaviors/communication/understanding is important for the NP to have?

What specific screenings / interventions will you incorporate into practice when providing care to a LGBT patient?

NSG 6330 Week 9 Discussion

Hormone Replacement Therapy

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will review the latest evidence based guidelines as they pertain to the case below .Discussion of the case is based on the course objectives and weekly content, which emphasize the core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, case study discussions are used to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .

Ms .Martin is a 55-year-old woman who has been on HRT for 4 years .HRT was prescribed because Ms .Martin was experiencing vasomotor symptoms associated with menopause .Her last mammogram was 2 years ago and last pap was 5 years ago .Ms .Martin made an appointment with her nurse practitioner to discuss discontinuing HRT after hearing and reading news reports about the dangers associated with the medication .Except for the HRT, Ms .Martin is taking no medication other than a daily vitamin .She had a tubal ligation after the birth of her third child but has had no other surgeries or history of any medical conditions .Her father had cardiovascular disease and died of a myocardial infarction at 77 years of age .Her mother was diagnosed with breast cancer at 81 years of age .Ms .Martin does not smoke and rarely drinks alcohol .She likes to work in her garden but is not involved in a formal exercise program .She has gained about 10 pounds since menopause .

What evidence-based information will you provide to Ms .Martin regarding her concerns of HRT? Discuss the advantages and risks associated with HRT .

What are your recommendations for Ms .Martin? Will you recommend continuing or discontinuing HRT and why?

What alternative treatments for menopausal symptoms will you discuss with Ms .Martin?

Discuss the recommended screening tests, using the latest evidence based guidelines that Ms .Martin should have .

What health promotion, maintenance, and prevention education would be important to provide to Ms .Martin?

NSG 6330 Discussions and Prophylactic Hysterectomy review Week 10 Discussion

Prophylactic Hysterectomy

This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered .For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned .

To support your work, use your course textbook readings and the South University Online Library .As in all assignments, cite your sources in your work and provide references for the citations in APA format .

Start reviewing and responding to the postings of your classmates as early in the week as possible .Respond to at least two of your classmates’ initial postings .Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion .Cite resources in your responses to other classmates .Complete your participation for this assignment by the end of the week .

For this assignment, you will review and reflect on the Prophylactic Hysterectomy article .This article can be applied to healthcare providers in the primary care and specialty settings .Discussion of the article is based on the course objectives and weekly content, which emphasize the core learning objectives for an evidence-based primary care curriculum .Throughout your nurse practitioner program, discussions are used to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice .NSG 6330 Discussions and Prophylactic Hysterectomy review

Discuss any “take-away” thoughts from the article .

What are the ethical dilemmas to consider with prophylactic surgeries?

Discuss the screenings/interventions/options/education that you would provide to a patient that has a strong family history of ovarian cancer .What if the patient has no health insurance? What resources could you offer to assist the patient?

 

Prophylactic Antibiotic Choice and Risk of Surgical Site Infection After Hysterectomy

OBJECTIVE

To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy.

METHODS

A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep–organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving beta-lactam antibiotics and those receiving alternatives to beta-lactam antibiotics. Patients receiving non-recommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving non-standard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results.

RESULTS

The study included 21,358 hysterectomies. The overall rate of any surgical site infection’ was 2.06% (N=441). Unadjusted rates of ‘any surgical site infection’ were 1.8%, 3.1% and 3.7% for beta-lactam, beta-lactam alternatives and non-standard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared to the beta-lactam antibiotics (reference group), the risk of ‘any surgical site infection’ was higher for the group receiving beta-lactam alternatives (OR 1.7, CI 1.27–2.07) or the non-standard antibiotics (OR 2.0, CI 1.31–3.1).

CONCLUSION

Compared to women receiving beta lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended beta lactam alternative or non-standard regimen.

Surgical site infections are associated with increased hospital length of stay and increased episode cost after surgery., In addition, surgical site infections are the most common reason for readmission after a wide variety of operations. The rate of overall surgical site infections (superficial, deep, and organ space) in hysterectomy has been reported to range between 1% and 4%., Hysterectomy is among the most common major operations in the United States (600,000 performed annually) and may result in 6,000 to 24,000 surgical site infections each year. Consequently, beginning October 1, 2015, inpatient post-hysterectomy surgical site infections were included in the Centers for Medicare and Medicaid Services calculations for Hospital-Acquired Condition Reduction Program metrics.

Preoperative prophylactic antibiotic administration has been shown to consistently reduce the rate of postoperative surgical site infections. The American College of Obstetricians and Gynecologists (the College) has issued guidelines for choosing appropriate preoperative prophylactic antibiotics; in addition, the Joint Commission’s Surgical Care Improvement Project has issued a list of procedure-specific prophylactic antibiotics. Studies have shown that compliance with these guidelines varies across institutions and procedures, and regimens not in compliance have involved both undertreated and overtreated cohorts.NSG 6330 Discussions and Prophylactic Hysterectomy review

The objective of the current study is to quantify the effects of preoperative antibiotic choice on surgical site infection rates after hysterectomy using data from a statewide surgical collaborative.

MATERIALS AND METHODS

A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative (herein also referred to as the collaborative) undergoing hysterectomy from July 2012 to February 2015. The collaborative is funded by the Blue Cross Blue Shield of Michigan/Blue Care Network, and it includes patients from all insurance payers (public and private). At each participating hospital, a trained, dedicated nurse abstractor collects patient characteristics, intraoperative processes of care (including the details of preoperative antibiotics administered), and 30-day postoperative outcomes from general and vascular surgery and hysterectomy cases. To ensure complete capture of the data, nurse abstractors make phone calls to the patients to determine whether they were admitted to a hospital other than the one in which the index surgery was performed. To reduce sampling error, a standardized data collection methodology is used whereby data abstraction is performed on only the first 25 cases of an 8-day cycle (alternating on different days of the week for each cycle). The standardized data collection methodology is routinely validated through scheduled site visits, conference calls, and internal audits. ,

Patients were included in the study if they were older than 18 years of age and were undergoing abdominal, vaginal, laparoscopic, or robotic hysterectomy. Patients with gynecologic malignancy and those undergoing hysterectomy for benign indications were included in the study. Patients with no recorded antibiotic information and those with missing surgical site infection information were excluded from the analysis. Michigan Surgical Quality Collaborative datasets provided to the researchers contain no patient, hospital or healthcare provider identifiers. Therefore, this study met the criteria for “exempt” status by the University of Michigan Institutional Review Board–Medical (HUM00073978).

The following information was available for analysis: age at the time of surgery; body mass index (BMI), calculated as weight/height (kg/m2); covariates associated with performance status, including American Society of Anesthesiologists (ASA) classification score (defined as a dichotomous variable an ASA class <3 or ≥3); and preoperative medical history, including diabetes mellitus (defined as requiring oral hypoglycemic agents and/or insulin), hypertension (defined as documentation in preoperative evaluation or of receiving antihypertension medications), and smoking status (defined as having smoked cigarettes, cigars, or pipe, chewed tobacco, or used marijuana within the past year). Preoperative transfusion was defined as having receiving a minimum of one unit of whole blood or packed red blood cells during the 72 hours before surgery. Patients with a final diagnosis coded as 179 to 184 based on the primary International Classification of Diseases, Ninth Revision (ICD-9) were defined as having the diagnosis of gynecologic cancer. All other ICD-9 diagnoses were defined as benign final pathology.

Approach to hysterectomy was categorized as open (all abdominal hysterectomy cases and all cases converted from laparoscopic or robotic cases) or minimally invasive, which encompassed laparoscopic (including robotic-assisted cases) and vaginal (including laparoscopic-assisted cases). Surgical complexity was calculated by adding the relative value units for each surgical procedure recorded for the patient. Operative times were reported in hours, from the start of the surgery (incision) to the closing of the skin incision.

Surgical site infections within 30 days of surgery were defined by the Centers for Disease Control and Prevention criteria. A superficial surgical site infection involved only skin and the subcutaneous tissue of the incision. In this study, deep and organ space surgical site infections were both considered “deep surgical site infections” because the fascia and muscle layers of the vaginal cuff are contiguous with the organ space. The primary outcome of the study was a composite outcome of any surgical site infection. The term any surgical site infection indicates when there was either a superficial or deep surgical site infection.NSG 6330 Discussions and Prophylactic Hysterectomy review

Preoperative antibiotics were categorized based on the criteria set forth by the the American College of Obstetricians and Gynecologists  and the Surgical Care Improvement Project. Patients receiving an antibiotic regimen recommended by ACOG or the Surgical Care Improvement Project were further categorized into those receiving beta-lactam antibiotics (e.g. cephalosporin, ampicillin-sulbactam, ertapenem) and those receiving alternatives to beta-lactam antibiotics (e.g. combination of clindamycin with gentamicin or quinolone). Patients receiving antibiotic regimens not recommended by the ACOG or the Surgical Care Improvement Project were categorized as those receiving overtreatment (e.g. recommended antibiotic with additional antibiotic) and those receiving non-standard antibiotics (e.g. Clindamycin alone). Patients who received overtreatment were excluded from the analysis because documented antibiotic resistance could account for such a decision.  illustrates the development of the antibiotic categories.

Breakdown of the antibiotic categories based on the American College of Obstetricians and Gynecologists (the College) usage guidelines and the Surgical Care Improvement Project (SCIP) usage guidelines. Antibiotic regimen details available in , available online at . *Patients receiving additional antibiotics to those recommended by the College and SCIP guidelines were categorized as overtreatment.

For all included patients, descriptive and comparative statistics of demographics, comorbidities, operative details, and postoperative surgical site infections were analyzed. For bivariate analyses, chi-square analysis or Fisher’s exact test was used. For continuous variables, parametric one-way analysis of variance or nonparametric Wilcoxon Mann-Whitney tests were used to assess significance in the bivariate relationship. To ascertain the independent effect of antibiotic categories included in the analysis, we constructed multivariate logistic regression models. Variables were excluded from model selection if they were not significant at a level of 0.1 in the bivariate analysis or if they were not related to the outcome in a clinically plausible manner.

For all logistic regression models, to account for violations in model assumptions due to non-independence of observations within clusters of data (hospital level), we used Huber-Eicker-White robust standard errors. These robust standard errors and the hospital-level clustering allowed the model to better reflect the collected data characteristics. We used STATA 14.0 SE for Macintosh (StataCorp LP, College Station, TX) for all analyses. Results of the logistic regression models were confirmed using propensity score matching (, available online at ).

RESULTS

A total of 22,992 patients undergoing hysterectomy were available in the collaborative database. Excluded from the analysis were cases with no recorded antibiotic information (n=418; 1.8%) and with missing surgical site infection information (n=29; 0.1%). Patients who received overtreatment were excluded from the analysis (n=1,187; 5.1%). There were 21,358 (93%) who were included in the analysis ().

Most of these patients received beta-lactam antibiotics (N=17,827; 79.1%), followed by the beta-lactam alternatives (N=2,878; 12.8%). The non-standard regimens were administered in 2.8% (N=653) of cases (). The majority of patients in the non-standard group received single agent antibiotics (Clindamycin alone − 67%; Gentamicin only − 8%) Details of the 15 different regimens included in this group are provided in , available online at .NSG 6330 Discussions and Prophylactic Hysterectomy review

The overall rate of any surgical site infection was 2.06% (N=441). Patients with any surgical site infection were older, had higher BMI, were more likely to have diabetes, were more likely to report tobacco use, received a preoperative transfusion, and had gynecologic cancer as a surgical indication. In addition, patients with any surgical site infection had higher use of open abdominal approach, higher median blood loss, higher complexity of surgery (measured by mean relative value units), and longer operative times (). Baseline comparison between the three groups of antibiotic categories is provided in . Patients receiving a beta-lactam antibiotics had lower incidence of tobacco use, ASA class 3, history of hypertension, and history of diabetes. The three groups did not differ in the operative time, blood loss, surgical complexity, and proportion of patients with malignancy. The beta-lactam antibiotics group had a higher proportion of patients undergoing open surgery than the other two groups. Unadjusted surgical site infection rates were 1.8% for beta-lactam antibiotics, 3.1% for beta-lactam alternatives, and 3.75% for non-standard antibiotics. Details of the unadjusted rates of any surgical site infection, superficial surgical site infections, and deep surgical site infections are provided in .

Table 1

Predictors of Surgical Site Infection (unadjusted)

Surgical Site Infection (any)


Variable Overall
N=22,358
Absent
N=22,917
Present
N=441
P

Demographics and Comorbidities

Age, y, median (SD) 48.1 (11.7) 48.1 (11.7) 47.9 (11.8) .8

BMI, N (%)
 ≥30 kg/m2 obese 10,150 (47.5) 9,879 (97.3) 271 (2.7) <.001
 <30 kg/m2 nonobese 11,208 (52.5) 11,038 (98.5) 170 (1.5)

Diabetes, N (%)
 Present 1,984 (8.8) 1,911 (96.3) 73 (3.7) <.001
 Absent 20,561 (91.2) 20,169 (98.1) 392 (1.9)

Smoker, N (%)
 Yes 4,991 (23.4) 4,864 (97.5) 127 (2.5) .006
 No 16,367 (76.6) 16,053 (98.1) 314 (1.9)

ASA class, N (%)
 ≤2 16,812 (78.7) 16,514 (98.2) 298 (1.8) <.001
 ≥3 4,546 (21.2) 4,403 (96.8) 143 (3.2)

History of hypertension, N (%)
 Present 6,358 (30) 6,209 (97.2) 176 (2.8) <.001
 Absent 14,973 (70) 14,708 (98.2) 265 (1.8)

Preoperative transfusion, N (%)
 Yes 146 (0.7) 139 (95.2) 7 (4.8) .02
 No 21,212 (99.3) 20,778 (98) 434 (2)

Final pathology, N (%)
 Cancer 1,997 (9.3) 1,911 (95.7) 86 (4.3) <.001
 Benign 19,261 (90.7) 19,006 (98.2) 355 (1.8)

Surgical Factors

Surgical approach, N (%)
 Open 5,797 (27.1) 5,569 (96.1) 228 (3.9) <.001
 Minimally invasive* 15,561 (72.9) 15,348 (98.6) 213 (1.4)

Estimated blood loss, mL, median (IQR) 100 (50–200) 100 (50–200) 200 (100–350) <.001

Surgical complexity, total RVU, mean (SD) 26.7 (14.1) 26.5 (13.9) 31.8 (21.7) <.001

Operative time, h, median (SD) 2.2 (1.3) 2.1 (1) 2.5 (1.3) <.001

Antibiotic Type

Beta-lactam antibiotics, N (%) 17,827 (83.5) 17,498 (98.2) 329 (1.8) <.001

Beta-lactam alternatives, N (%) 2,878 (13.5) 2,790 (96.9) 88 (3.1)

Non-standard 653 (3) 629 (96.3) 24 (3.7)

ASA, American Society of Anesthesiologists; BMI, body mass index; PCN, penicillin; RVU, relative value units.

*Laparoscopic, vaginal, and robotic hysterectomy.

Table 2

Baseline Comparison of Characteristics Between the Antibiotic Groups

Variable Beta-lactam antibiotics
N=17,827
Beta-lactam alternatives
N=2,878
Non-standard
N=653
P
Demographics and Comorbidities


Age, y, median (SD) 48 (11.4) 48.5 (12.3) 48 (12.2) .09
BMI, kg/m2, mean (SD) 30.8 (8) 31.6 (8) 31.7 (9) .001
Diabetes present, N (%) 1,461 (8.2) 305 (10.6) 68 (10.4) .001
Tobacco user, N (%) 4,088 (22.9) 730 (25.4) 173 (26.5) .003
ASA class ≥3, N (%) 3,632 (20.4) 744 (25.9) 170 (26) <.001
History of hypertension, N (%) 5,245 (29.4) 931 (32.3) 209 (32) .03
Preoperative transfusion, N (%) 122 (0.7) 23 (0.8) 1 (0.2) .1
Gynecologic cancer, N (%) 1,624 (9.1) 310 (10.8) 63 (9.6) <.001

Perioperative Factors


Surgical approach, open, N (%) 4,880 (27.4) 757 (26.3) 160 (24.5) <.001
Estimated blood loss, mL, median (IQR) 100 (50–200) 100 (50–200) 100 (50–199) .6
Surgical complexity, total RVU, mean (SD) 25.9 (12.8) 26.8 (13.4) 25.4 (13.4) <.001
Operative time, h, mean (SD) 2.2 (1) 2.2 (1) 2 (1) .2

Surgical Site Infection (unadjusted)


Any, N (%) 329 (1.8) 88 (3.1) 24 (3.7) <.001
Superficial, N (%) 165 (0.9) 41 (1.4) 15 (2.3) <.001
Deep–organ, N (%) 167 (0.9) 47 (1.6) 10 (1.5) .003

ASA, American Society of Anesthesiologists; BMI, body mass index; IQR, interquartile range; PCN, penicillin; RVU, relative value units.

Multivariate logistic regression models were constructed for any surgical site infection, superficial surgical site infections, and deep surgical site infections.  summarizes the independent effect of factors included in the regression models. Compared to the beta-lactam antibiotics (reference group), patients receiving the beta-lactam alternatives had increased risk of any surgical site infection (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.27–2.07, P<.001), superficial surgical site infections (OR 1.5, 95% CI 1.04–2.09, P=.03), and deep–organ space surgical site infections (OR 1.7, 95% CI 1.27–2.4, P<.001). Similarly, compared to the beta-lactam antibiotics (reference group), patients receiving any non-standard regimen had at least twice the risk of any surgical site infection (OR 2.0 95% CI 1.31–3.1, P<.001), superficial surgical site infections (OR 2.5, 95% CI 1.46–4.34, P<.001) but did not differ significantly in the rate of deep–organ space (). The adjusted rate of any surgical site infection with respect to the antibiotic categories is shown in . Results of the logistic regression were validated using propensity score matching (, ).

Figure 1

Adjusted rates of overall surgical site infection by antibiotic category. Rates adjusted for patient factors (age, body mass index, American Society of Anesthesiologists category, history of diabetes, gynecologic malignancy, and tobacco use) and operative factors (surgical time, blood loss, and surgical complexity). Red dashed lines indicate 95% confidence interval bounds for referent category.NSG 6330 Discussions and Prophylactic Hysterectomy review

Table 3

Logistic Regression Model: Independent Predictors of Surgical Site Infection)

Variable adjusted for in logistic regression model Any SSI Superficial SSI Deep SSI

Unadjusted OR Adjusted OR 95% CI P Unadjusted OR Adjusted OR 95% CI P Unadjusted OR Adjusted OR 95% CI P

Antibiotic category
 Beta-lactam antibiotics Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Beta-lactam alternatives 1.7 1.62 1.27–2.07 <.001 1.6 1.5 1.04–2.09 .03 1.8 1.7 1.2–2.4 <.001
 Non-Standard 2.1 2.02 1.31–3.1 <.001 2.5 2.5 1.46–4.34 .001 1.7 1.6 0.8–3.1 .1

Surgical time (per hour) 1.3 1.23 1.14–1.33 <.001 1.3 1.14 0.98–1.3 .08 1.3 1.26 1.14 –1.39 <.001

BMI
 <30 kg/m2 nonobese Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 ≥30 kg/m2 obese 1.8 1.5 1.2–1.9 <.001 2.3 1.8 1.2–2.7 <.001 1.4 1.2 0.8–1.6 .2

Smoking status
 Nonsmoker Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Smoker 1.46 1.18–1.8 <.001 1.5 1.7 1.2–2.2 <.001 1.2 1.27 0.9–1.7 .14

ASA category
 <3 Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 ≥3 1.8 1.12 0.9–1.4 .3 2.2 1.2 0.8–1.7 .5 1.4 1.1 0.8–1.5 .5

Surgical complexity (per RVU) 1.02 1.01 0.9–1.01 .13 1.02 1.01 0.9–1.02 .1 1.01 1.002 0.9–1.01 .9

Diabetes
 Absent Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Present 1.8 1.36 1.05–1.76 .02 2.2 1.5 1.04–2.2 .03 1.4 1.3 0.8–1.8 .24

Final pathology
 Benign Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Cancer 2.4 1.7 1.3–2.2 <.001 3 1.8 1.3–2.6 .01 1.8 1.5 0.9–2.5 .08

Surgical route
 MIS Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Open 3 2.6 2.1–3.1 <.001 4.2 3.5 2.6–5 <.001 2 1.9 1.37–2.6 <.001

ASA, American Society of Anesthesiologists; BMI, body mass index; CI, confidence interval; MIS, minimally invasive surgery (vaginal, laparoscopic, and robotic hysterectomies); OR, odds ratio; PCN, penicillin; Ref, referent category; RVU, relative value units.

The overall rate of non-standard antibiotics uses in the collaborative dropped from 5.2% to 2.5% over the study time period. ()

Proportion of patients over time enrolled in the Michigan Surgical Quality Collaborative receiving nonstandard antibiotic regimens per the American College of Obstetricians and Gynecologists usage guidelines and the Surgical Care Improvement Project usage guidelines.NSG 6330 Discussions and Prophylactic Hysterectomy review

DISCUSSION

In this retrospective analysis of patients undergoing hysterectomy in the Michigan Surgical Quality Collaborative, we found that the choice of antibiotic regimen given before hysterectomy independently predicts the rate of any surgical site infection. Beta-lactam antibiotics (cephalosporins, ampicillin-sulbactam, ertapenem) are associated with the lowest rates of surgical site infections. Recommended beta-lactam alternatives (e.g. Clindamycin plus Gentamicin or Quinolone or Aztreonam) and patients receiving non-standard regimens (e.g. Gentamicin only, Clindamycin only) have a significantly higher risk of surgical site infections. One possible explanation is that beta-lactam antibiotics are highly effective against skin flora (Streptococcus species, Staphylococcus aureus, and coagulase-negative staphylococci), which are the predominant organisms that cause surgical site infections. Regimens that do not contain a beta-lactam antibiotic are inferior in controlling these organisms. 

Given this increased risk, patient-reported allergy to penicillin (PCN) should be thoroughly investigated to ascertain its validity and severity. Previous studies have shown that because of the fear of PCN anaphylaxis, clinicians frequently accept a diagnosis of PCN allergy without obtaining a detailed history of the reaction.  In our study, approximately 12% of the patients received a beta-lactam alternative antibiotic regimen, a prevalence consistent with the self-reported PCN allergy described in the literature.  It is important to remember that cephalosporin cross-reactivity shown in skin testing is present in only 10% of patients with a true PCN allergy. , Patients with negative results on PCN skin testing and those without a history of anaphylactic reaction to PCN can safely receive cephalosporin. ,, Routine use of PCN skin testing could potentially increase the use of cephalosporins and therefore reduce the use of alternative antibiotics in perioperative settings. ,

The current analysis quantifies the association of administering antibiotics not recommended by the College or by Surgical Care Improvement Project guidelines before hysterectomy. Wright et al reported that 2.3% of patients undergoing gynecologic surgery received antibiotics not recommended by the guidelines. However, the authors did not report the effect of non-adherence to guidelines on surgical site infection rates. In our study, the majority of patients who received a non-standard regimen received a single-agent antibiotic (clindamycin, gentamicin, or metronidazole). Previous studies have shown these single agents are inferior to cephalosporins.  Studies have also shown that adherence to Surgical Care Improvement Project’s surgical site infection reduction bundle into surgical safety checklists can significantly improve antibiotic infusion timing and antibiotic selection.  In our study, for each quarter starting in July 2012, the percentage of patients in the collaborative who receive non-standard antibiotics has consistently decreased (). Although precise reasons of this improvement are likely multifactorial, the participation of hospitals in a functional collaborative encouraging evidence-based practices seems to improve the quality of surgical care across the hospitals. 

This study has several strengths. The Michigan Surgical Quality Collaborative is a statewide collaborative that uses standardized data collection methods and dedicated nurse abstractors who are regularly audited for interrater reliability. Although the collaborative is limited to a single state, it includes a mix of academic and community hospitals, making the data more generalizable. In addition, our logistic regression modeling accounted for the clustering effect from physician/facility preferences. Studies have shown that the quality of data from collaboratives such as the Michigan Surgical Quality Collaborative and the National Surgical Quality Improvement Project is similar to that of chart review and much better than that of administrative claims-based databases. 

Limitations of our study include reported heterogeneity in surgical site infection reporting in the literature; however, collaborative abstractors are trained to reduce variations in reporting. Moreover, the Centers for Disease Control and Prevention criteria for surgical site infection diagnosis may underestimate the true incidence of surgical site infections by excluding cases of cellulitis by as much as threefold.  Even though the nurse abstractors follow up with patients by phone within the 30-day period to avoid missing capturing complications if patients seek care in another hospital, potential for underreporting surgical site infections remains. Lastly, data on the appropriate timing and dosage of antibiotics were not available, and variations in these could have affected the conclusions of this study.

In summary, efforts to decrease surgical site infections could focus on adherence to recommended preoperative antibiotic guidelines and thorough evaluation of patient reported penicillin allergies in order to increase the number of patients receiving beta lactam antibiotics.

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NSG 6330 Discussions and Prophylactic Hysterectomy review

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