Deep Sternal Wound Infection After Cardiac Surgery
Coronary Artery Bypass Grafting (CABG) or commonly known as heart bypass surgery is a heart operation or procedure to improve blood flow to the heart (NIH, 2020). This procedure usually is necessary when the coronary arteries supplying blood to the heart have become narrowed or are blocked by plaque that has built overtime. The procedure is done by using blood vessels from another part of the body, like the leg or arm and connects them to the aorta and the coronary artery, creating a new channel for blood to flow (American Heart Association, 2017).
One complication that may arise after CABG surgery which can be life threatening is deep sternal wound infection (DSWI) or mediastinitis. According to The Journal of Thoracic Disease, deep sternal wound infection has an incidence rate ranging from 0.2% to 8% reportedly and the mortality rate varying from 8% to 45%. This complication is associated with an increase in medical cost, incurring an estimated 2.8 times more than the cost for patients without any complications during the post-operative period, prolonged hospital stays, where patients with DSWI or mediastinitis accumulate an average of 20 additional hospital days, and sometimes would require reoperation (Singh, 2011).
The National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC) is a healthcare-associated infection (HAI) tracking system (NHSN, 2020). As a widely used tracking system for healthcare-associated infections, NHSN’s goal is to eliminate healthcare-associated infections by use of the data collected and provide the data needed in order to address and identify the problem areas of healthcare-associated-infections and to measure the progress of prevention efforts (NHSN, 2020). With this goal, the CDC and NHSN has provided the surveillance definition of specific types of infections for reporting of surgical site infections (SSI) for mediastinitis or DSWI. Patients with mediastinitis or DSWI must meet at least one of the following criteria: patient has organism(s) identified from mediastinal tissue or fluid by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment, patient has evidence of mediastinitis on gross anatomic or histopathologic exam, patient has at least one of the following signs or symptoms: fever (>100.4°F), chest pain, or sternal instability and at least one of the following events, purulent drainage from mediastinal area and/or mediastinal widening on imaging test (CDC/NHSN, 2020).
In line with CMS’s Merit Based Incentive System, a program designed to promote reporting of quality information by eligible professionals, the Society of Thoracic Surgeons (STS) has developed quality performance measures in the areas of adult cardiac, general thoracic, and congenital surgery (STS, 2020). One performance measure is for risk-adjusted deep sternal wound infection which was endorsed by the National Quality Forum on December 6, 2011.
This performance measure is described as percent of patients aged 18 years and older undergoing isolated CABG (without pre-existing renal failure) who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and mediastinum requiring operative intervention over all patients undergoing isolated CABG over a twelve month period with patients under the following conditions; wound opened with excision of tissue (I&D) or re-exploration of mediastinum, positive culture unless patient on antibiotics at time of culture or no culture obtained and treatment with antibiotics beyond perioperative prophylaxis (STS, 2020).
Events of surgical infection sites after cardiac surgery, such as mediastinitis or DSWI has met at least one of the conditions under the Deficit Reduction Act of 2005 which prompted the ruling of payment for HAC (Hospital Acquired Conditions). Under the Deficit Reduction Act of 2005, On July 31, 2008, CMS included 10 categories of conditions that were selected for the HAC (Hospital Acquired Conditions) payment provision. Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG) was included in the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule wherein payment implications began October 1, 2008 (CMS, 2020).
References:
American Heart Association. (2017). American Heart Association. Retrieved from heart.org: https://www.heart.org/-/media/data-import/downloadables/2/7/5/pe-abh-what-is- coronary-bypass-surgery-ucm_300434.pdf
CDC/NHSN. (2020, January). CDC/NHSN Surveillance Definitions for Specific Types of Infections. Retrieved from CDC.GOV: https://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf
CMS. (2020, February 11). Hospital Acquired Conditions. Retrieved from cms.gov: https://www.cms.gov/Medicare/Medi care-F ee-for-S ervice- Payment/HospitalAcqCond/Hospital-Acquired_Conditions
NHSN. (2020, September). National Healthcare Safety Network. Retrieved from cdc.gov: https://www.cdc.gov/nhsn/index.html
NIH. (2020). NIH National Heart Lung and Blood Institute. Retrieved from nih.gov: https://www.nhlbi.nih.gov/health-topics/coronary-artery-bypass-grafting
STS. (2020). Performance Measure Descriptions: Adult Cardiac Surgery Measures. Retrieved from sts.org: https://www.sts.org/quality-safety/performance- measures/descriptions#DeepSternalWound
Singh, K. A. (2011, February). PMC US National Library of Medicine National Institutes of Health. Retrieved from ncbi.nlm.nih.gov: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140234/#:~:text=Deep%20sternal%20
