To define the epidemiology, risk factors, and unadjusted cost of hemorrhages related to cardiothoracic operations.

We conducted two case-control studies to evaluate the risk of hemorrhage following cardiothoracic operations. The definition of hemorrhage required one of the following: reoperation for bleeding, postoperative loss of greater than 800 mL of blood over 4 hours, or surgeon-diagnosed excessive intraoperative bleeding.

The cardiothoracic surgery service of a university hospital.

Of 511 patients undergoing cardiothoracic operations, 93 (18%) met the definition of hemorrhage. In the first case-control study, 3 (14%) of 21 cases and 0 of 42 controls died (odds ratio [OR], 15.0; 95% confidence interval [CI95], 1.18-191.55). Compared with controls, cases received significantly more packed red blood cells intraoperatively (OR, 1.18/100 mL; CI95, 1.01-1.38), and significantly more platelets (OR, 3.26/100 mL; CI95, 1.47-7.26) and fresh frozen plasma (OR, 1.73/100 mL; CI95, 1.05-.84) in the intensive-care unit. Cases were more likely than controls to receive protamine postoperatively (OR, 3.74; CI95, 1.27-11.02). Previous sternotomy, preoperative aspirin or heparin, and preoperative laboratory values did not predict bleeding. The median unadjusted hospital cost was $3,458 higher for patients who suffered hemorrhage than for controls.

To decrease costs, hetastarch (acquisition cost $45/500 mL) was substituted for albumin (acquisition cost $76/100 mL) in the pump priming solution (estimated possible cost savings, $7,000-$53,000/year). Because hemorrhage rates increased subsequently, we conducted a second case-control study that identified patient age (P=.02) and use of greater than 5 mL/kg of hetastarch (OR, 1.82) as risk factors for hemorrhage. The cost of treating hemorrhages exceeded all estimates of possible cost savings ($7,000-$53,000 per year).

Our definition of hemorrhage identified patients who required increased volumes of blood products and who had an increased crude mortality rate and a higher unadjusted cost of hospitalization. Patient age and hetastarch use were risk factors for hemorrhage. Efforts to save money by substituting less expensive products inadvertently may increase costs by increasing the probability of perioperative adverse events.

To follow over time surgical-site infection (SSI) rates in patients admitted to the hospital on the same day as their elective surgery (group I), and to compare these rates with those of other surgical patients who also required postoperative hospitalization but either were hospitalized for 1 or more days immediately prior to surgery or underwent surgery on a nonelective basis (group II).

Observation of overall SSI rates over time for group I and II patients and study of risk factors associated with increased SSI rate among group I neurosurgical patients.

A 900-bed, tertiary-care community hospital with >10,000 surgical procedures performed each year on patients requiring postoperative hospital stay.

A total of 48,464 surgical procedures were performed on consecutive patients from 1990 to 1994, with 18,794 (39%) involving group I patients. In addition, 511 consecutive procedures performed on neurosurgical patients requiring postoperative hospitalization from July 1994 to May 1995 were analyzed.

In 1990, the overall SSI rate of group I patients was significantly lower than that of group II patients (0.4% vs 1.3%, relative risk [RR], 3.6; 95% confidence interval [CI95], 2-6.4; P<.0001), but, by 1994, there was no longer any significant difference between the SSI rates of group I and II patients (1.8% and 1.6%, respectively; P=.38). In 1994, the SSI rate in group I neurosurgical patients was significantly greater than that of group II patients (3.4% vs 0.4%; RR, 8.3; CI95, 1.05-66; P=.02). During the period April through September 1994 (warm months), group I neurosurgical patients were associated with a significantly lower American Society of Anesthesiologists score and SSI risk index (based on National Nosocomial Infection Surveillance System data) and a higher likelihood of having “clean-class” wounds, but significantly greater-than-expected SSI rate when adjusted for patient risk index and type of procedure (4.7% vs 1.4%; RR, 3.3; CI95, 1.3-8.6; P=.02). During the same period, the observed and expected SSI rates were not significantly different for group II neurosurgical patients.

As a whole, the SSI rates among patients undergoing elective surgery on the same day of their hospital admission is no longer significantly lower than that of other patients who also require postoperative hospitalization. For certain procedures, such as those commonly performed on the neurosurgical service, elimination of preoperative hospital stay may be associated with greater-than-expected risk of SSI.

To determine if an apparent increase in bloodstream infections (BSIs) in patients with central venous catheters (CVCs) was associated with the implementation of a needleless access device.

Retrospective cohort study using a derived CVC-days factor for estimating appropriate denominator data.

A 350-bed urban, acute, tertiary-care hospital.

BSI surveillance data were obtained, and high-risk areas for BSIs were determined. A random 5% sample of medical records was used to estimate CVC days, and a cohort study was conducted to compare BSI rates before and during needleless device use. A survey was conducted of nursing needleless-device practices.

The surgical intensive-care unit (SICU), the medical intensive-care unit, and the solid organ transplant unit (OTU) were identified as high-risk units. Using existing surveillance BSI data and the estimated CVC days, the catheter-related BSI rates in the high-risk surgical patients were significantly higher during the needleless-device period compared with the preneedleless-device period (SICU, 9.4 vs 5.0/1,000 CVC days; OTU, 13.6 vs 2.2/1,000 CVC days). A survey of the nurses revealed that 60% to 70% were maintaining the needleless devices correctly.

We observed a significant increase in the BSI rate in two surgical units, SICU and OTU, associated with introduction of a needleless device. This increase occurred shortly after the needleless device was implemented and was associated with nurses' unfamiliarity with the device, and needless-device use and care practices different from the manufacturer's recommendations.

To analyze risk factors for, and the role of methicillin resistance in, mortality in Staphylococcus aureus bacteremia.

Nested case-control study.

General teaching hospital with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) strains, in São Paulo, Brazil.

136 patients over 14 years old with documented S aureus bacteremia. Those who died were compared with those who survived at least 14 days.

Mortality within 14 days of bacteremia was 39% (53/136). Mean age was 47 years. Hospital-acquired bacteremia represented 86% (117/136) of episodes. In 26% (35/136), infection was related to an intravascular catheter and in 13% (17/136) to the respiratory tract. Septic shock occurred in 22% (30/136) of cases. MRSA was isolated in 66% (90/136). Multivariate analysis identified three variables that were significantly and independently associated with mortality: site of entry (lung, odds ratio [OR], 17.0; unknown, OR, 12.3; others, OR, 6.6); occurrence of shock (OR, 8.9), and resistance of S aureus to methicillin (OR, 4.2).

Our study shows that S aureus bacteremia has a high mortality, especially when the lung is the source of infection and when shock develops; resistance to methicillin may be another risk factor for poor outcome.