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Abstract
Keywords
Introduction
Methods
Results
Discussion
Conclusions
Conflicts of interest
Contributorship
Ethical statement
Financial disclosure
Appendix A. Supplementary data
Research Data
References
Tables (2)
Table 1
Table 2
Extras (1)
Online data
Elsevier
International Journal of Orthopaedic and Trauma Nursing
Volume 30, August 2018, Pages 3-7
International Journal of Orthopaedic and Trauma Nursing
Practice development in orthopaedics and trauma
Use of ASEPSIS scoring method for the assessment of surgical wound infections in a Greek orthopaedic department
Author links open overlay panelPanagiotaCopanitsanouaVasileios A.KechagiasbTheodoros B.GrivascPeterWilsond
https://doi.org/10.1016/j.ijotn.2018.03.003Get rights and content
Abstract
Background
In Greece there is no systematic assessment of surgical wounds with the use of a validated instrument, while the ASEPSIS scoring method has been widely used internationally.
Aim
To examine the frequency of wound infections and their correlations both with patient background factors, as well as surgery factors, with the use of ASEPSIS.
Methods
In this prospective, observational study, participants undergoing orthopaedic surgeries in a large hospital in Greece were assessed during hospitalisation and the first month after discharge using the ASEPSIS wound assessment tool. The principles of the Declaration of Helsinki were applied. Non-parametric statistical analyses were performed using SPSS 20.0.
Results
In total, 111 patients participated; nearly half (49.5%) had a total ASEPSIS score of “0”. Almost 3 out of 4 patients (76.6%) had an ASEPSIS score under or equal to “10” (satisfactory healing) and only 3.6% had a minor or severe surgical wound infection. The ASEPSIS score was only positively correlated to longer surgery duration and longer postoperative stay.
Discussion
The frequency of surgical wound infections in orthopaedic patients in Greece is comparable to that described in the literature. ASEPSIS could be used for assessing patients and as a performance indicator in Greek orthopaedic departments.
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Keywords
Surgical wound infectionOrthopaedic patientsOrthopaedic surgeryOrthopaedic traumaElective orthopaedic surgeryASEPSIS
Introduction
Surgical wound infection is defined as an infection of the surgical area following elective or emergency surgery when microorganisms may be inoculated into the wound, resulting in local or systemic response (Horan et al., 1992). Surgical wound infections constitute the second most frequent healthcare-associated infection after pneumonia (Centers for Disease Control and Prevention, 2016) and they are associated with prolonged hospital stay (Wilson et al., 2006), mortality (Sherlaw-Johnson et al., 2007) and higher costs (Kapadia et al., 2014); about 60% of unplanned readmissions are due to surgical wound infections (McCormack et al., 2013).
A surgical wound infection can occur through contact with contaminated hands/gloves, from the air or from the patient’s microbial skin flora during surgery. Data on the incidence of surgical wound infections in Greece remain scarce, as there is no systematic recording in hospitals. Furthermore, a misconception seems to persist that surgical wounds should be assessed objectively by a surgeon (Ashby et al., 2010). Finally, the problem of the lack of a widely accepted method for the assessment of surgical wounds also applies in Greece.
The suitability of the ASEPSIS scoring method for use in a high volume orthopaedic department in Greece was considered in this study. The questions included whether the ASEPSIS assessment method is applicable to a specific type of surgery and whether the instrument is brief, simple to use and can be completed by both physicians and nurses (Wilson et al., 2006). The purpose of the present study was to examine the frequency of wound infections and provide insights into the connections between patient factors (e.g. age), surgery factors (e.g. emergency surgery, duration of surgery) and the use of ASEPSIS.
Background
The ASEPSIS scoring method has been used in the assessment of surgical wounds of orthopaedic patients (Ashby et al., 2009), after cardiac surgery (Bennett-Guerrero et al., 2010; Heiner et al., 2002; Malhotra et al., 2014), after colorectal surgery (Hedrick et al., 2015; Whitney et al., 2015) and patients undergoing other procedures (Bickel et al., 2011; Whitney et al., 2015). In a systematic review, by Bruce et al. (2001), thirteen wound assessment scales were identified, the most widely referenced of which was ASEPSIS, while the use of the remaining scales seems to be limited. In the same study ASEPSIS was identified as reliable, comparable and reproducible (Bruce et al., 2001), while similar results are not reported for other scales. In a study comparing the wound infection rates among orthopaedic patients as assessed with the ASEPSIS scoring method, the US Centres for Disease Control (CDC) and the UK Surgical Site Infection Surveillance Service (SSISS), the overall infection rates were 8% according to the CDC, 4% according to the SSISS and 3% according to the ASEPSIS. In the same study the CDC and SSISS definitions were found to be subjective and dependent on the interpretation of the surgeon, while ASEPSIS is reported as an objective and reproducible method (Ashby et al., 2009).
The incidence of surgical wound infections after orthopaedic surgery is estimated to be around 2.1%, while factors such as diabetes, smoking, prolonged hospital stay (Jain et al., 2015; Ribeiro et al., 2013), duration of surgery longer than 3 h and history of previous operations (Li et al., 2013) are identified in the international literature as risk factors. Orthopaedic patients undergoing emergency procedures (e.g. for a hip fracture) have higher risk of wound infection when compared to patients who undergo elective procedures (e.g. a total joint replacement) (Vasilakis et al., 2011).
The type of wound (with dirty wounds presenting higher incidence in comparison to clean wounds) (Ercole et al., 2011; Maksimović et al., 2008; Thu et al., 2005), an American Society of Anesthesiologists (ASA) score greater than 2 (Maksimović et al., 2008; Thu et al., 2005), a greater number of persons in the operating room (Maksimović et al., 2008; Olsen et al., 2008), procedures involving external fixation (Thu et al., 2005) and the absence and/or suboptimal time of antibiotic prophylaxis (Li et al., 2013; Olsen et al., 2008) are also associated with increased risk of the development of a surgical wound infection.
In the Greek literature, in a prospective study which did not solely include orthopaedic patients, surgical wound infection rates were 5.3%, and 47.3% of these infections presented after the patients’ discharge from the hospital (Roumbelaki et al., 2008). In another Greek study, it was reported that surgical wound infections had a frequency of 4.2% in clean wounds and 12.9% in clean-contaminated wounds, while 53.1% of these infections were also observed postoperatively (Tourmousoglou et al., 2008). Bekiari et al. (2013) found that 7.7% of surgical patients had developed surgical wound infections, although this was a pilot study. In a study byGikas et al. (2004), which took place in fourteen hospitals, it was found that surgical wound infections had a rate of 4.2–4.5% and it seemed this indicated a downward trend (Gikas et al., 2004). However there is a lack of Greek studies about the frequency of surgical wound infections specifically in orthopaedic patients.
Methods
Study design-sample
This was a prospective, observational study of patients who were undergoing emergency or elective orthopaedic surgeries in a large hospital in Greece. Patients participating in the study had to be aged over 18 years, be hospitalised exclusively in the orthopaedic department, have undergone an orthopaedic surgery requiring incision (i.e. not arthroscopy), be hospitalised for at least two nights and give verbal consent to voluntary participation. Patients with dementia were not excluded because we believed this would lead to bias, as many patients in orthopaedic departments are of older age and likely to suffer from dementia. In this case the patient’s relative would give the informed consent.
Data collection
During the patients’ initial assessment, their background factors were recorded (e.g. age, gender, comorbidities) based on information from patient records and/or from the patients themselves. During hospitalisation, information regarding the length of hospital and preoperative stay, type and duration of surgery, type of trauma, type of anesthesia, prophylactic and therapeutic administration of antibiotics, body temperature and complications (local; e.g. compartment syndrome and systematic; e.g. delirium, respiratory and/or urinary tract infections, gastrointestinal complications) were also recorded.
All surgical wounds were assessed using ASEPSIS by an orthopaedic surgeon both during hospitalisation as well as one month after hospitalisation. We attempted to ensure assessments took place at least twice (ideally for 5 of the first 7 postoperative days), but mainly during scheduled and needed dressing changes in order to avoid the repeated unnecessary change of the dressing and the subsequent risk for infection. Computer software was used to interpolate scores for gaps between days when scores were available. This approach has proven to work well in circumstances when a patient can only be seen twice (Wilson et al., 2006). The study took place from November 2014 to November 2016.
Measures – instruments
According to ASEPSIS the scores for each surgical wound are based on nine characteristics; 1) need for additional treatment (e.g. antibiotics), 2) drainage of pus, 3) wound debridement, 4) serous exudate, 5) erythema, 6) purulent exudate, 7) separation of deep tissues, 8) isolation of bacteria and 9) prolonged stay as inpatient (Wilson et al., 1986). In addition, points are added for prolonged hospital stay, use of antibiotics to treat wound infections, isolation of bacteria from a wound swab and drainage of pus under local or general anaesthesia within the first month. The ASEPSIS score can be calculated during the patient’s hospitalisation, after discharge or can be the sum of these two scores (Vasilakis et al., 2011), as in the present study.
The ASEPSIS was considered suitable for our purpose, since it was selected following a literature review in which we searched for an instrument with questions that are not specific to certain types of surgery and are brief, simple to use and easy to complete both by physicians and nurses. The instrument was also required to lead to reproducible results, characteristics that ASEPSIS scoring method has as it includes assessments of both objective and subjective characteristics (Wilson et al., 2006).
The translation of the instrument followed the process described in the literature (Jones, 1987). The ASEPSIS scoring method was translated from English to Greek, with the original authors’ permission and then back-translated. The Greek version was checked by a panel of experts and minor corrections were made. Finally, the ASEPSIS was pilot tested in 30 patients. The instrument was found easy to apply and no further corrections were needed. Then the ASEPSIS was systematically used for the evaluation of orthopaedic patients’ surgical wounds.
Ethical issues
Institutional Review Board approval was obtained (11193/17-09-2014, date of approval 31-10-2014) and the principles of the Declaration of Helsinki (World Medical Association, 2013) were applied throughout the study. Patients were properly informed about the purpose and the procedures of the study and a verbal informed consent was obtained. Participation was voluntary during the whole study and participants were reminded they were able to withdraw at any stage without their treatment being affected.
Statistical analysis
The data were analysed for possible relationships between the occurrence of surgical wound infections and both the patients’ background factors, as well as factors related to the operation and hospitalisation, in order to identify potentially modifiable factors for preventing these infections. Data analysis was performed with descriptive statistics and, as our data did not follow the normal distribution, with the appropriate non-parametric tests. The ASEPSIS score was treated as a continuous variable. In all tests statistical significance was set at 0.05. The statistical analyses were performed using SPSS 20.0.
Results
In total, 111 patients participated with a mean age of 70.51 years (Standard Deviation- SD 19.5). Most of them (59.5%) were undergoing surgery for fractures (e.g. fragility fractures of the hip). All surgical wounds were clean or clean contaminated and were performed for a primary surgical procedure (not a revision). The duration of surgery was 72.21 min (SD 30.65 min). The average length of hospital stay was 10.15 days (SD 5.75 days). The majority of patients experienced no complications (51.4%); however, 21.6 of patients presented one complication and 0.9% presented seven complications during hospitalisation (Table 1).
Table 1. Descriptive results.
N (%)
Gender Female 76 (68.5)
Male 35 (31.5)
Retired Yes 74 (66.7)
No 25 (22.5)
Missing 12 (10.8)
Education Primary school 52 (46.8)
High school 16 (14.4)
University/technological education 7 (6.3)
Missing 36 (32.4)
Body weight Low weight 24 (21.6)
Normal weight 56 (50.5)
High weight 31 (27.9)
Surgery Fracture 66 (59.5)
Total arthroplasty 45 (40.5)
Anaesthesia Epidural 92 (82.9)
General 19 (17.1)
Comorbidities Diabetes 21 (18.9)
Rheumatoid disease 1 (0.9)
Cardiac disease 19 (17.1)
Chronic obstructive pulmonary disease 7 (6.3)
Hypertension 59 (53.2)
Malignancy 5 (4.5)
Dementia 21 (18.9)
Antithrombotic therapy Yes 20 (18.0)
No 91 (82.0)
Smoking Yes 14 (12.6)
No 81 (73.0)
Missing 16 (14.4)
Complications Yes 46 (41.4)
No 57 (51.4)
Missing 8 (7.2)
The mean number of days postoperatively thatthe assessments took place with the ASEPSIS was between 2.34 and 5.11. Almost half of the patients (49.5%) had a total ASEPSIS score of “0”, while 76.6% had an ASEPSIS score under or equal to“10” (satisfactory healing); 19.8% had a score between “11” and “20” (disturbance of healing); 2.7% a score between “21” and “30” (minor wound infection) and none between “31” and “40” (moderate wound infection). Only 0.9% (n = 1) of patients had a score higher than 41 (i.e. “56”, severe wound infection) (Table 2). The latter male patient had a high ASEPSIS score due to prolonged length of stay, rehospitalisation and administration of antibiotics. Thus, 3.6% of patients had a minor or severe surgical wound infection according to the ASEPSIS scoring method. Only 3 patients needed a wound swab and/or blood cultures, all of which were negative. None of these patients had an ASEPSIS score higher than “13”. Also, 6 patients (5.4%) needed rehospitalisation during the first month due to problems in the healing process. Of these patients, 3 needed wound debridement (one of them presented with separation of deep tissues). One female patient (1.5%) who needed rehospitalisation had positive blood culture results; she was administered antibiotics and had a diagnosis of a surgical wound infection.
Table 2. Frequencies of ASEPSIS scores.
ASEPSIS score N %
0-10 (satisfactory healing) 83 76.6
11-20 (disturbance of healing) 24 19.8
21-30 (minor wound infection) 3 2.7
31-40 (moderate wound infection) 0 0.0
>41 (severe wound infection) 1 0.9
Total 111 100.0
The ASEPSIS score was not correlated to patients’ background factors and surgery factors and it was only positively related to longer surgery duration (r = 0.246, p = 0.01) and longer postoperative stay (r = 0.286, p = 0.004), although long postoperative stay is included in the ASEPSIS, so this was an expected correlation.
Discussion
In Greece, there is no systematic assessment of surgical wounds with a validated instrument, which may lead to poor surveillance. Yet patients who are admitted to Greek hospitals are prescribed excessive chemoprophylaxis compared to surgical patients in other countries (Gikas et al., 2004). The ASEPSIS scoring method has been widely used internationally to evaluate surgical wound healing, is brief and simple to use, therefore we believe it it to be the most suitable instrument to use. The purpose of this study was to examine the frequency of surgical wound infections and the connection between surgical wound infections and patient background factors and surgery factors with the use of ASEPSIS. Our ultimate purpose is to use ASEPSIS on a regular basis for the surveillance of surgical wound infections in Greek surgical departments.
In the present study, the mean number of days for the assessments of surgical wounds was according to the original authors’ recommendations (Wilson et al., 2006) and the majority of patients had scores of satisfactory healing. Only 3.6% of participants had a minor or severe surgical wound infection according to the ASEPSIS. These rates are comparable to those reported in the literature; the incidence of surgical wound infections in a large study of orthopaedic patients was reported to be between 3% and 8% (Ashby et al., 2010). In other studies of orthopaedic patients who are generally considered as “low risk” for the development of surgical wound infection, the incidence of surgical wound infections is reported as between 1.8% (Ercole et al., 2011) and 12.5% (Thu et al., 2005) or to be as high as 17.2% (Ribeiro et al., 2013), while in a number of patients, 4.8% (Maksimović et al., 2008) to 28.9% (Thu et al., 2005) are detected with an infection after hospital discharge. In a study of patients who had undergone total joint arthroplasties in Scotland, 2.4% of infections occurred up to one year after surgery, while the frequency was only 0.4% during hospitalisation (Health Protection Scotland, 2010). In the same study, 84.6% of surgical wound infections were detected after the inpatient stay and, of this total, 53.8% were during the first 30 postoperative days (Health Protection Scotland, 2010). In our study, one person with a surgical site infection was also detected during the first month after discharge, highlighting the importance of patient follow-up after discharge.
In a Greek study of surgical patients, wound infection rates were 5.3% (Roumbelaki et al., 2008), while in another study surgical wound infections had a rate of 4.2% in clean wounds and 12.9% in clean-contaminated wounds (Tourmousoglou et al., 2008). Bekiari et al. (2013) found that 7.7% of surgical patients had developed surgical wound infections. In the study of Gikas et al. (2004), which took place in fourteen hospitals, surgical wound infections had a rate of 4.2–4.5%. However, there is a lack of Greek studies about the incidence of such infections solely in orthopaedic patients.
Although our sample size was small and, therefore, the correlations with background patient factors and surgery should be taken with caution, the results provide insights about possible correlations. During hospitalisation, participants were older (with mean age of 70.51 years) and were mainly undergoing surgeries for fractures (e.g. fragility fractures of the hip), meaning they suffered with many comorbidities. However, no patient factor was related to ASEPSIS scores in this study. In the scientific literature, patient factors such as diabetes (Jain et al., 2015; Olsen et al., 2008), smoking (Jain et al., 2015), increased body mass index, hypertension, bleeding disorders (Pugely et al., 2015) and a history of previous operations (Li et al., 2013) are identified as risk factors, findings that were not confirmed in our study. For patients with surgical wound infections which are detected after discharge, older age has been reported as a risk factor (Thu et al., 2005). In Greek studies it has been found that the patient’s age, comorbidity (e.g. rheumatoid arthritis, diabetes mellitus, obesity, peripheral vascular disease), abnormal blood glucose levels perioperatively (Masgala et al., 2012), female gender (Bekiari et al., 2013), American Society of Anesthesiologists Score (Bekiari et al., 2013; Masgala et al., 2012), and previous multiple surgeries (Roumbelaki et al., 2008) were connected to wound infections. In the Greek literature, it has been found that there is no relationship between inflammation markers such as C-reactive protein or erythrocyte sedimentation rate and inflammation in patients who undergo orthopaedic surgeries (Gelalis et al., 2011). In the same study, positive intraoperative cultures did not lead to postoperative infection, while negative cultures did not exclude the possibility of a postoperative infection.
Regarding the surgical factors, the ASEPSIS score was positively related to longer duration of surgery and longer postoperative stay, although the latter was an expected correlation. The type of surgery and of anaesthesia and even the preoperative length of hospital stay were not related to ASEPSIS scores, which may mean that the factors affecting wound healing have more to do with the surgical technique and the aseptic methods rather than other factors. The longer duration of surgical procedure [longer than 120 min (Thu et al., 2005)-180 min (Li et al., 2013)] has also been confirmed in this study as a risk factor. In a Greek study, which did not include only orthopaedic patients, prolonged duration of surgery and type of chemoprophylaxis were identified as risk factors for wound infections (Roumbelaki et al., 2008). In another study, there were no significant differences in the effectiveness of different chemoprophylaxis in patients undergoing total hip replacement (Tyllianakis et al., 2010). Bekiari et al. (2013) found that patients with increased duration (longer than 24 h) of chemoprophylaxis administration had increased risk for wound infections. In a study of orthopaedic patients, type of chemoprophylaxis, prolonged hospitalisation, type of surgery and type of anaesthesia were connected to infections (Masgala et al., 2012). Finally, in a Greek study of surgical patients, participants who had longer postoperative hospitalisation, contaminated wounds and central venous catheters also had higher rates of surgical wound infections (Gikas et al., 2004). More research is needed regarding the effects of patients and surgery/wound factors on the incidence of surgical wound infections in Greece.
As ASEPSIS has been found easy and quick to use, it could be used as an instrument not only for assessing patients, but also as a performance indicator in orthopaedic departments to monitor overall surgical wound infections. This is of special importance in Greece, a country with severe understaffing of public hospitals (Kondilis et al., 2013) and poor recording of surgical wound infections. As validation studies are only applicable to the setting in which they were conducted, validation of ASEPSIS on a sample of orthopaedic patients in a Greek hospital cannot be generalised to patients in other countries or settings (Bruce et al., 2001).
Accurate wound surveillance is not a simple process; different definitions give different rates of infection and make comparisons between surgeons, hospitals and countries impossible. ASEPSIS seems to be easy to apply in a Greek hospital, but further research is needed about its practicability and feasibility in other Greek settings. Furthermore, more research is needed internationally to investigate whether the ASEPSIS represents a practical scoring method for the assessment of surgical wounds in other countries. The ultimate aim would be for all hospitals to use the same scoring method, so accurate comparisons of infection rates could be made, both at national and international level.
The limitations of our study include the relatively small sample size which was mostly due to the difficulty in assessing the wounds, as we did not want to remove the dressings unnecessarily. Τhe follow-up was relatively short given that it is adequate for surgical wounds of e.g. general surgery, but not enough for wounds with implants such as orthopaedic surgical wounds; therefore, the incidence of surgical wound infection may have been underestimated. However, in other studies of patients with orthopaedic surgeries the follow-up period was also short (Ashby et al., 2010; Wilson et al., 2004). Finally, the fact that data came from a single orthopaedic department means that the results should be viewed with caution and cannot be generalised.
Conclusions
This is the first time the ASEPSIS scoring method has been used in Greece, so the Greek version has not been widely tested. Further studies are needed with larger sample sizes to conclude whether the ASEPSIS is an easy and appropriate instrument for the regular assessment of surgical wound infections. However, the results of the study will likely contribute to the systematic use of a potentially suitable instrument for the assessment of surgical wounds, their early identification and their recording and monitoring over time, in order to improve the quality of health care provided in surgical patients in Greece.
Conflicts of interest
The authors have no conflict of interest.

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