7/24/2019 Pi is 0002937813006261

1/17490.e1 American Journal of Obstetrics & Gynecology NOVEME! "01#

!

$G$ %a&ers '''.AJOG.org

$urgical site infection after (ysterectomyAeuMuro Gas(a' )a*e+ M,- Alean/ra M. Mc%enco'+ M,- Ma/eline A. ,ic*iascoec(ea+ M,-

,eanna . Martin+ M%2- Elisabet( A. Ere*son+ M,+ M%2

OJE35VE6 Our ob7ecti8e 'as to estimate t(e occurrence of surgical site infections $$5: after (ysterectomy an/ t(e associate/ ris*

factors.

$;,< ,E$5GN6 =e con/ucte/ a crosssectional analysis of t(e"00>

"009 American 3ollege of $urgeons National $urgical ?uality

n @ ""1 'omen:. !is* factors t(at 'ere associate/ 'it( cellulitis'ere route of (ysterectomy 'it( an a/7uste/ o//s ratio 9AO!: of #.4

9>B confi/ence inter8al C35D+ "."e."":for la&arotomy com&are/

'it( t(e 8aginal a&&roac(+ o&erati8e time F>t( &ercentileAO!+

1.4- 9>B 35+ 1.40e".44:+American $ociety of Anest(esia class #"

5m&ro8ement %rogram &artici&ant use /ata files to analyHe (ysterec 9AO!+ 1.9- 9>B 35+ 1.#1e".4#:+bo/y mass in/e 40*gIm

9AO!+

tomies. ,ifferent routes of (ysterectomy 'ere com&are/. (e&rimaryoutcome 'as to i/entify t(e occurrence of #0/ay su&erficial $$5cellulitis: after (ysterectomy. $econ/ary outcomes 'ere t(e occur

rence of /ee an/ organs&ace $$5 after (ysterectomy. )ogisticregression mo/els 'ere con/ucte/ to furt(er e&lore t(e associationsof ris*s factors 'it( $$5 after (ysterectomy.

!E$;)$6 A total of 1#+"" 'omen 'ere inclu/e/ in our final analysis.

(e occurrence of &osto&erati8e cellulitis after (ysterectomy 'as

1.B

".>- 9>B 35+ 1.>e#.0:+ an/ /iabetes mellitus 9AO!+ 1.>4- 9>B35+

1.0e"."4: (e occurrence of /ee& an/ organs&ace $$5 'as

1.1B n @ 1>4 'omen: after (ysterectomy.

3ON3);$5ON6 Our fin/ing of t(e /ecrease/ occurrence of su&erficial

$$5 after t(e 8aginal a&&roac( for (ysterectomy reaffirms t(e role for

8aginal (ysterectomy as t(e route of c(oice for (ysterectomy.

ey 'or/s6 (ysterectomy+ outcome+ &osto&erati8e com&lication+surgical site infection

3ite t(is article as6 )a*e AG+ Mc%enco' AM+ ,ic*iascoec(ea MA+ et al. $urgical site infection after (ysterectomy. Am J Obstet Gynecol "01#-"096490.e19.

ecently+ ;nite/ $tates (ealt(care

initiati8es sonsore/ by t(e 3en

ters for Me/icare an/ Me/icai/ $er8ices3M$: an/ t(e Joint 3ommission on

t(e Accre/itation of 2ealt(care Organi

Hations (a8e targete/ &re8entable

(os&ital acuire/ infections+ suc( as

ostoerati8e surgical site infections

$$5:+ as a riority in imro8ing atient

safety. Effecti8e January "01"+ 3M$

reuire/ all Me/icare certiKe/

(ositals to ublically re&ort clinical

/ata an/ outcome measures in a

L$ystematic 3linical ,atabase !egistry for

General $urgery in t(e 2os&ital5n&atient

?uality !eorting %rogram.1

(e

conse uence for an institution or

(osital not reorting 'ill be aayment enalty as of October "01#.

(e " surgical roce/ures t(at 'ere

i/entiKe/ by 3M$ in t(is recent

man/ate for &ublic re&orting of

ostoerati8e $$5 are colon surgeryan/ (ysterectomy.

O8er t(e last " /eca/es+ remar*able

a/8ancements (a8e been ma/e in t(e

c(oice of (ysterectomy routes. Alt(oug(t(e occurrence an/ ris* factors of

$$5 after total ab/ominal (ysterectomy

A2: (as been reorte/+" neit(er t(e

occurrence nor t(e ris* factors of&ost

(ysterectomy $$5 (a8e been reorte/

by (ysterectomy route."4 etter un/erstan/ing of ris* factors for $$5 after

(ysterectomy can (el target efforts at

t(e re/uction of mo/iKable ris*s to

re8ent infections. A//itionally+ un/er

stan/ing ris* factors for $$5 after

(ysterectomy can lea/ to better ris*

stratiKcation in t(e reorting of uality

outcomes. Our ob7ecti8e 'as to estimate

t(e occurrence of #0/ay ostoerati8e

$$5 after all routes of (ysterectomy an/to i/entify associate/ ris* factors.

rom t(e ,eartment of Obstetrics+ Gynecology+ an/ !ero/ucti8e $ciences+

7/24/2019 Pi is 0002937813006261

2/17NOVEME! "01# American Journal of Obstetrics & Gynecology 490.e"

MAE!5A)$ AN, ME2O,$=e con/ucte/ a secon/ary /atabase analysis of t(e "00>"009 American 3ollege

of $urgeons National $urgical ?uality 5mro8ement %rogram A3$ N$?5%:

articiantuse /ata Kles to analyHe t(e /ata of 'omen '(o un/er 'ent

(ysterectomies erforme/ by gy necologic ser8ices. (e A3$ N$?5% is a

national rogram for surgical uality

imro8ement t(at collects uniform /ata

on atients '(o un/ergo surgical&ro

ce/ures. 2osital articiation in t(e

A3$ N$?5% rogram is 8oluntary an/

000"9#IP#.00 Q "01# Mosby+ 5nc. All rig(ts reser8e/. (tt& 6 II/./oi.or g I10.101I7.a7og."01#.0.01 conK/ential. (is information is col

lecte/ by a formal c(art re8ie' rocess

http://dx.doi.org/10.1016/j.ajog.2013.06.018http://dx.doi.org/10.1016/j.ajog.2013.06.018http://dx.doi.org/10.1016/j.ajog.2013.06.018http://dx.doi.org/10.1016/j.ajog.2013.06.018

7/24/2019 Pi is 0002937813006261

3/17

$G$ %a&ers '''.AJO G .org

A)E 1

,emogra&(ic an/ clinical c(aracteristics of #0/ay ostoerati8esuerficial surgical site infection after (ysterectomy n C1#+"" 'omen:

an/ its uality control measures are

furt(er /escribe/ on t(eir 'ebsite

(t t6 II'' ' .a c sns i .o r g:. Eemtion

status for t(is stu/y 'as obtaine/ in

'riting from t(e .4: "> 0.: .49

Et(nicity6 2is&anic+ n B: " 1".": "10 1.0: .14

,iabetes mellitus+ n B: 41 1.: 9" ."B: R .001

Eclusion criteria inclu/e/ 1:

male se+ ": 'omen 'it( t(e

/iagnosis of current &regnancy+ #:

surgical &roce/ure 'it(in #0 /ays

before (ysterectomy+ 4: 3urrent

%roce/ural erminology 3o/ing $ystem+

4t( e/ition 3%4:+ co/e incon sistent

'it( (ysterectomy+ >: 3%4 co/e t(at

in/icates el8ic eenteration &roce

2istory of cerebro8ascular acci/ent'it( neurologic /eficit+ n B:

1 0.>: > 0.>B: 1.0 /ure at t(e time of (ysterectomy+ an/ :

'omen 'it( a /iagnosis of reoerati8e3urrent smo*er+ n B: >1 "#.1: "1 19.B: ."0

o/y mass in/e+ n B: R .001

R#0 *gIm"

#>.#: >9 >>.9:

#0 an/ R40 *gIm"

4 ##.>: 4>4 ##.:

40 *gIm"

9 #1.": 14#9 10.:

Ascites+ n B: ".: 104 0.: R .01

a

infection t(at inclu/es sesis+ systemic

inammatory resonse syn/rome+ an/

setic s(oc* imme/iately before (yster

ectomy. After eclusion for t(ese

criteria+ t(e remaining articiants

'ere 'omen '(o un/er'ent

(ysterectomy.

2ysterectomy route 'as assigne/

base/on 3%4 co/ing of t(e rimary&ro

;nintentional 'eig(t loss+ n B:

unctional status6 /e&en/ent for acti8itiesof /aily li8ing+ n B:

2ysterectomy for gynecologiccancer+ n B:

%reo&erati8e anemia6 (ematocrit9R#B:+n B:

%reo&erati8e creatinine le8elF1.>mgI/)+ n B:

American $ociety of Anest(esiologists

class #+ n B:

4 1.: " 0.>: .0"

" 0.9: 9 0.: .

#" 14.>: 1 .4: R .001

4 "".#: "9 "".: .94

# 1.: > 0.9: .1

9# 4".1: ">"1 1.>: R .001

ce/ure6 A2+ ab/ominal

suracer8ical (ysterectomy $32:+

total 8aginal (ys terectomy V2:+

laaroscoicassiste/ 8aginal

(ysterectomy )AV2:+ total laa

roscoic (ysterectomy )2:+ an/

laa roscoic $32 )A$32:. =e

furt(er eamine/ $$5 base/ onab/ominal in cisions6 1: laarotomy

A2 or $32:+ ": laaroscoic

incisions )AV2+ )2+ or )A$32:+ or

#: V2. inally+ 'e eamine/ $$5

base/ on 8aginal cuff in

5ntrao&erati8e bloo/ transfusion+ n B: 1> .: #"9 ".4: R .001

b

cisions6 1: no 8aginal cuff incisions $32

or )A$32: 8s ": 8aginal cuff incisions

=or* relati8e 8alue unit

O&erati8e time F>t(&ercentile/uration+ n B:

1. >.1 1.# #. R .001

9# 4".1: ## "4.: R .001

A2+ V2+ )AV2+ an/ )2:.

!is* factors for $$5 'ere elore/

an/ groue/ into t(e follo'ingcategories6

y&e of anest(esia6 general+ n B: ""1 100.0: 1#+111 9.4: .001

http://www.ajog.org/http://www.ajog.org/http://www.acsnsqip.org/http://www.acsnsqip.org/http://www.acsnsqip.org/http://www.acsnsqip.org/http://www.ajog.org/

7/24/2019 Pi is 0002937813006261

4/17

$G$ %a&ers'''.AJOG.org=oun/ class+ n B: .0

13lean 0 ## 0.":

"3leanIcontaminate/ "1> 9.#: 1#+44# 9.:

#3ontaminate/ > ".#: 9" 0.:

4,irty 1 0.>: ## 0.":

a)oss of 10B of bo/y 'eig(t in t(e &re8ious mont(s not because of eercise or /ieting-

b,ata are gi8en as mean $,.

)a*e. $urgical site infections after (ysterectomy. Am J Obstet Gynecol "01#.

/emogra(ic features+ reoerati8e

me/ ical comorbi/ities+ an/

intraoerati8e factors. ,emogra(ic

features inclu/e/ age+ race+ an/

et(nicity. =omen 'ere /ic(otomiHe/

into t(e " age categories R0 yearsol/ an/ 0 years ol/: because of a

re8iously /emonstrate/ nonlinear

association bet'een age an/ t(e log

o//s of ostoerati8e infection.

%reoerati8e comorbi/ities inclu/e/

me/ical /iag noses+ obesity+

(ysterectomy for gyneco logic

cancer+ reoerati8e functionalin a//ition to a #0/ay &osto&era

ti8e follo'u e8aluation of atients.>

Variables t(at are collecte/ inclu/e

reoerati8e c(aracteristics+ surgical in

formation+ an/ #0/ay ostoerati8e

com&lications. (e A3$ N$?5%

/atabase

status+ unintentional 'eig(t loss+

&reo& erati8e laboratory /ata+ an/

American $ociety of Anest(esia A$A:

classiKcation.

http://www.ajog.org/http://www.ajog.org/

7/24/2019 Pi is 0002937813006261

5/17

Me/ical /iagnoses t(at 'ere

consi/ere/ inclu/e/ /iabetes mellitus+ a

(istory of cerebro8ascular acci/ents

3VA: 'it( neurologic /eKcit+ ascites+

reoerati8e corticosteroi/ use+ an/

obesity. Obesity 'as classiKe/ base/ on

bo/y mass in/e M5:. =omen 'erecategoriHe/ as (a8 ing normal 'eig(t

M5+ R#0 *gIm":+ obesity M5+ #0

an/ R40 *gIm":+ an/ morbi/ obesity

M5+ 40 *gIm":.

=omen '(o (a/ un/ergone (ysterec

tomies for gynecologic cancer 'ere

i/en tiKe/ by 3%4 co/es t(at 'ere

consistent 'it( lym( no/e /issection

or ra/ical /ebul*ing+ t(e /iagnoses of

reoerati8e ascites+ reoerati8e

/isseminate/ cancer+ reoerati8e

c(emot(eray+ an/ &reo& erati8era/iation t(era&y. unctionalstatus 'as

/eKne/ as a 'omanSs ability to

erform acti8ities of /aily li8ing+

'(ic( inclu/e/ bat(ing+ fee/ing+

/ressing+ toi leting+ an/ mobility an/

'as categoriHe/ as eit(er in/een/ent

or /een/ent. ;n intentional 'eig(t

loss 'as use/ as a mar*er of frailty

an/ 'as /eKne/ as loss of F10B of

bo/y'eig(t o8er t(e re8ious

mont(s. %reoerati8e laboratory /ata

'ere use/ to i/entify anemia an/ renalcomromise. Anemia 'as /eKne/ as

(e matocrit of R#B base/ on t(e

Kn/ings of =u et al

an/ 2eisler et

al.9

!enal com&romise 'as /eKne/ as a

creatinine le8el of F1.>mgI/) base/ on

t(e Kn/ings of ,o'/y et al.10

5ntraoerati8e factors t(at 'ere

elore/ inclu/e/ t(e tye of

/ata Kle of t(e A3$ N$?5%.1"

(ese

/eKnitions 'ere also base/ on criteria

set by t(e 3enters for ,isease 3ontrol

an/ %re8ention 3,3:.1#

(e rimary

outcome 'as t(e occurrence of #0/ay

suerKcial $$5 cellulitis: after (ys

terectomy. 3ellulitis 'as /eKne/ as an

infection t(at in8ol8e/ only s*in or

subcutaneous tissue of t(e surgical inci

sion. $econ/ary outcomes 'ere t(e

occurrence of /ee an/ organsace

$$5 an/ urinary tract infection ;5:

after (ysterectomy. ,ee an/ organ

sace $$5 inclu/e/ infections t(at

in8ol8e/ /ee soft tissues fascia an/

muscle: at an/ aroun/ t(e surgical

incision an/ in fections in any art

of t(e bo/y t(at 'as oene/ or

maniulate/ /uringt(e oerati8e roce/ure. (is inclu/es

8aginal cuff cellulitis an/ 8aginal cuff

abscess+ eritonitis+ an/ el8ic abscess.

,ee an/ organsace $$5 'ere consi/ere/ as 1 category+because t(ese " cate

gories 'ere /ifKcult to /istinguis( '(en

(ysterectomy is consi/ere/ to be t(e

rimary roce/ure. inally+ 'e eam

ine/ ostoerati8e ;5+ '(ic( 'as

/eKne/ by 3,3 criteria for

symtomatic ;5 an/ asymtomatic

bacteriuria+ '(ic( ta*e into accountt(e recent use of in/'elling cat(eters

an/ t(e age of t(e&atient.1#

A)E "

,escriti8e statistics+ $tu/ent t test+

%earson c"+ an/ is(er eact test"si/e/: 'ere erforme/ for bi8ariate

analysis. (ree logistic regression mo/els

'ere con/ucte/ to furt(er elore t(e

associations of ris*s factors for

cellulitis+ /ee an/ organsace $$5+an/ &ost oerati8e ;5 after

(ysterectomy.+9

Variables t(at 'ere associate/ 'it(

$$5 'ere i/entiKe/ for otential

inclusion in t(e Knal mo/el base/ on

bi8ariate analysis % R .1:. Variables

'ere a//e/ to t(e mo/el in a

ste'ise fas(ion 'it( t(e use of

for'ar/ selection %.0>:. A/7uste/ o//s ratios AO!s:

an/

9>B conK/ence inter8als 35s: 'erecalculate/. $tatistical analysis 'as &er

forme/ 'it( $AA statistical

soft'are 8ersion 11.0- $tata

3ororation+ 3ollege $tation+ T: an/

$A$ statistical soft'are 8ersion 9."-

$A$ 5nstitute 5nc+ 3ary+ N3:.

!E$;)$A total of "#+>9 articiants 'ere

classiKe/ as (a8ing un/ergone a gyne

cologic roce/ure in t(e "00>

"009A3$ N$?5% articiant use /ataset.

(e follo'ing eclusions 'ere ma/e

from t(e Knal analysis6 1: male se

n @ >1:+ ": 'omen 'it( t(e /iagnosis

of current regnancy n @ 41:+ #:

surgical roce/ure 'it(in #0 /ays

anest(esia+ 'oun/ classiKcation+ intra

oerati8e bloo/ transfusion+ an/ &roce

/ural /ifKculty. 3oncomitant roce/ures

an/ roce/ural /ifKculty 'ereaccounte/ for by an eamination of t(e

total 'or* relati8e 8alue units an/

total oerati8e time. %roce/ures (a/

bet'een 1 an/

3% co/es. o consi/er t(e com&leity

of all t(e /ifferent &ossible

combinations of

)ogistic regression mo/el for association of cellulitis after (ysterectomy

Variable A/7uste/ o//s ratio 9>B 35 % 8alue

!oute of (ysterectomy

otal 8aginal (ysterectomy referent: 1 U U

)aarotomya

#.4 "."e."" R .001

)a&arosco&ic incisionsb

1.4> 0.#e".> ."0

O&erati8e time F>t(&ercentile /uration 1.4 1.40e".44 R .001

roce/ures+ 'or* relati8e 8alue units

for all concomitant roce/ures 'ere

totale/. Oerati8e time 'as

categoriHe/ as a

American $ociety of Anest(esiologists

class #

o/y mass in/e+ *gIm"

1.9 1.#1e".4# R .001

/ic(otomous 8ariable abo8e an/ belo'

t(e >t( ercentile+ base/ on

&re8ious 'or*by 3ul8er et al+11

'(o

/emonstrate/ t(at o&erati8e time ofF

>t(&ercentileisa ris* factor for $$5. or(ysterectomies in t(e A3$ N$?5% /ataset+ t(e o&erati8e time ofF>t(&ercentile 'as 149 minutes. $$5 categories 'ere /eKne/ by t(e criteria foun/

7/24/2019 Pi is 0002937813006261

6/17

in t(e articiant use

R#0 referent: 1 U U

#0 an/ R40 1.#1 0.94e1.1 .11

40 ".> 1.>e#.0 R .001

,iabetes mellitus 1.>4 1.0e"."4 .0"

a)a&arotomy inclu/e/ total ab/ominal (ysterectomy an/ su&racer8ical (ysterectomy-

b)a&arosco&ic incisions inclu/e/

la&arosco&icassiste/ 8aginal (ysterectomy+ total la&arosco&ic (ysterectomy+ an/ la&arosco&ic su&racer8ical (ysterectomy.

)a*e. $urgical site infections after (ysterectomy. Am J Obstet Gynecol "01#.

7/24/2019 Pi is 0002937813006261

7/17

A)E #

,emogra&(ic an/ clinical c(aracteristics of #0/ay ostoerati8e /ee or organsace surgical siteinfection after (ysterectomy nC 1#+"":

Variable

$urgical site infection

,ee&Iorgans&ace

nC 1>4:

No /ee&Iorgans&ace

nC 1#+: % 8alue

Age+ n B: 1.0

R0 y 1>" 9.: 1#+444 9.4:

0 y " 1.#: ""4 1.:

!ace6 '(ite+ n B: # 4.4: #"1 0.9: .001

Et(nicity6 2is&anic+ n B: #" "0.: "1> 1>.9: .1"

,iabetes mellitus+ n B: "# 14.9: 1000 .#: R .01

2istory of cerebro8ascular acci/ent 'it( neurologic /eficit+ n B: 4 ".: " 0.>: R .01

3urrent smo*er+ n B: 4 #0.>: "> 19.: .001

o/y mass in/e+ n B: R .001

R#0 *gIm"

44.": 0 >>.:

#0 an/ R40 *gIm"

>0 #".>: 4> ##.:

40 *gIm"

# "#.4: 14" 10.:

Ascites+ n B: 4 ".: 10 0.: .04

;nintentional 'eig(t loss+ n B:a

" 1.#: 4 0.>: .1

unctional status6 /e&en/ent for acti8ities of /aily li8ing+ n B: " 1.#: 9 0.: .#0

2ysterectomy for gynecologic cancer+ n B: 1# .4: 90 .>: .#"

%reo&erati8e anemia6 (ematocrit 9R#B:+n B: >0 ##.: "94 "".: R .01

%reo&erati8e creatinine F1.>mgI/)+ n B: # ".: > 0.9: .0

American $ociety of Anest(esiologists class #+ n B: >4 #>.1: ">0 1.: R .001

5ntrao&erati8e bloo/ transfusion+ n B: >.": ## ".>: .0

=or* relati8e 8alue unitb

1. 4. 1.# #. .1#

O&erati8e time6 F>t(&ercentile /uration+ n B: >1 ##.1: #4"0 ">.0: .0#

y&e of anest(esia6 general+ n B: 14 9.1: 1#+14 9.>: ."

=oun/ class+ n B: .1

13lean 0 ## 0.":

"3leanIcontaminate/ 1>0 9.4: 1#+>0 9.:

#3ontaminate/ # ".0: 94 0.:

4,irty 1 0.: ## 0.":

a)oss of 10B of bo/y 'eig(t in t(e &re8ious mont(s not because of eercise or /ieting-

b,ata are gi8en as mean $,.

)a*e. $urgical site infections after (ysterectomy. Am J Obstet Gynecol "01#.

before (ysterectomy n @ 1>:+ 4:3%

4 co/e inconsistent 'it( (ysterectomy

n @ 94#:+ >: 3%4 co/e t(at in/i

cate/ el8ic eenteration roce/ure att(e time of (ysterectomy n @ 10:+ an/

: 'omen 'it( /iagnosis of &reo&

erati8e infection t(at inclu/e/

sesis+ systemic inammatory

resonse syn /rome+ an/ setic

s(oc* imme/iately

before (ysterectomy n @ 14":. A total of

1#+"" 'omen un/er'ent (ysterectomy

an/ 'ere inclu/e/ in our Knal analysis.

3ellulitis(e o8erall occurrence of cellulitis

suerKcial $$5: after (ysterectomy 'as

7/24/2019 Pi is 0002937813006261

8/17

1.B nIN @ ""1I1#+"":. our 'omen

0.0#B: recei8e/ a /iagnosis of bot(ostoerati8e cellulitis an/ /ee or

organs&ace $$5. 'el8e 'omen

0.0B: recei8e/ a /iagnosis of bot(

&ost oerati8e cellulitis an/ ;5.

Variables t(at 'ere associate/ 'it(

cellulitis on bi8ariate analysis

inclu/e/ /iabetes mellitus % R .

001:+ M5 category % R

.001:+ reoerati8e ascites % R .

01:+ unintentional 'eig(t loss % @.0":+

7/24/2019 Pi is 0002937813006261

9/17

(ysterectomy for cancer % R .001:+

A$A class # % R .001:+ 'or* relati8e

8alue unit % R .001:+ use of general

anest(esia % @.001:+ an/ an o&erati8e

time F>t( ercentile % R .001- able

1:.

A)E 4

)ogistic regression mo/el for association of /ee or organ s&acesurgical site infection after (ysterectomy

A/7uste/ o//s

Variables t(at 'ere associate/ 'it(#0/ay ostoerati8e cellulitis on mul

ti8ariate logistic regression 'ere t(e route

VariableAmerican $ociety of Anest(esiologists

class #

ratio 9>B 35 % 8alue1.1 1.">e"." R .01

of (ysterectomy 'it( an AO! of #.4

3urrent smo*er 1.99 1.40e".# R .0019>B 35+ "."e."": for laarotomy in

cisions comare/ 'it( 8aginal a&&roac(+

oerati8e time F>t( ercentile

AO!+

2istory of cerebro8ascular acci/ent'it( neurologic /eficit

4.41 1.>4e1".> R .01

1.4- 9>B 35+ 1.40e".44:+A$A class #

AO!+ 1.9- 9>B 35+ 1.#1e".4#:+

morbi/ obesity M5+ 40 *gIm"-

AO!+ ".>-9>B 35+ 1.>e#.0:+ an/ /iabetes mel

litus AO!+ 1.>4- 9>B 35+ 1.0e"."4-

able ":.

,ee& an/ organsace $$5

(e occurrence of /ee an/ organ

sace

$$5 'as 1.1B nIN @ 1>4I1#+"": after

%reo&erati8e anemia (ematocrit+ R#B: 1." 1."1e".4# R .01

o/y mass in/e+ *gIm"

R#0 referent: 1 U U

#0 an/ R40 1.19 0."e1.4 .#

40 "."# 1.4#e#.49 R .001

35+confi/ence inter8al.

)a*e. $urgical site infections after (ysterectomy. Am J Obstet Gynecol "01#.

(ysterectomy. No 'omen 'ere catego

riHe/ as (a8ing bot( a /ee s&ace $$5

an/ an organsace $$5. 'entyone

'omen 0.1B: 'ere /iagnose/ 'it(bot( &ost o&erati8e /ee&Iorgans&ace$$5 an/ ;5. Variables t(at 'ereassociate/ 'it( /ee an/ organs&ace$$5 on bi8ariate analysis inclu/e/ race% @ .001:+ /iabetes mel litus % R .

01:+ (istory of 3VA 'it( neurologic

/eKcit % R .01:+ current smo*ing %

@ .001:+ obesity category % @ .11:+

reoerati8e ascites % @ .04:+

reoerati8e anemia % R .01:+ A$A

class # % R .001:+ an/ an oerati8e

time F>t( ercentile % @ .0#- able

#:.

Variables t(at 'ere associate/ 'it(

/ee& an/ organs&ace $$5 on

multi8ariate logistic regression inclu/e/

A$A class # AO!+ 1.1- 9>B 35+

1.">e".":+current smo*ing AO!+

1.99- 9>B 35+

1.40e".#:+(istory of 3VA 'it( neuro

logic /eKcit AO!+ 4.41- 9>B 35+

1.>4e1".>:+ &reo&erati8e anemiaAO!+

1."- 9>B 35+ 1."1e".4#:+ an/ morbi/

obesity AO!+ "."#- 9>B 35+1.4#e#.49- able 4:. =(en 'e

eamine/ (ysterec tomy route+ bot(

by ab/ominal incisions an/ by

8aginal cuff incisions+ 'it( /ee an/

organs&ace $$5+ 'e /i/ not Kn/ anysigniKcant associations.

;

45

%ostoerati8e ;5 occurre/ in ".B

of 'omen nIN @ #0I1#+"":

after

(ysterectomy. Variables t(at 'ere asso

ciate/ 'it( ostoerati8e ;5 on bi8ar

iate analysis inclu/e/ (istory of 3VA

'it( neurologic /eKcit % @ .01:+ A$A

class # % R.01:+ an/ an o&erati8e time

F>t( ercentile % R .001- able >:.

Variables t(at 'ere associate/ 'it( &ost

oerati8e ;5 on multi8ariate logistic

regression 'ere a (istory of 3VA 'it(

neurologic /eKcit AO!+ #."9- 9>B 35+

1.41e.0:+ current corticosteroi/ use

AO!+ ".#- 9>B 35+ 1.14e4.90:+ an/

oerati8e time F>t( ercentile AO!+

1.- 9>B 35+ 1.>"e"."9-able :.

Occurrence of $$5by route of

(ysterectomy

=(en 'e eamine/ /ifferent routes

of (ysterectomy A2+ $32+ )2+

)A$32+ )AV2+ an/ V2:+ 'e notice/

similarities in t(e occurrence of $$5

by ab/ominal incision ty&e able :. =e

eamine/ routes of (ysterectomy solely

base/ on ab/ominal incisions la&arot

omy+ laaroscoic incisions+ an/ no

ab/ominal incisions: an/ note/ t(at t(e

route of (ysterectomy 'as associate/

'it( su&erKcial $$5+ but not /ee&Iorgan

sace $$5 or ostoerati8e ;5. inally+

'e eamine/ t(e association of &ost

7/24/2019 Pi is 0002937813006261

10/17

(ysterectomy $$5 by t(e resence or

absence of 8aginal cuff incisions $32 8s

8aginal colotomy: an/ foun/ no asso

ciation 'it( any ostoerati8e $$5.

3OMMEN

=e foun/ t(e o8erall occurrence of

bot(

#0/ay cellulitis suerKcial $$5:

an/ /ee an/ organsace $$5 after

(yster ectomy to be ".B. (e

occurrence of ;5 after (ysterectomy

'as #.0B.

(e follo'ing ris* factors 'ereassoci ate/ 'it( t(e occurrence of

ostoerati8e cellulitis6 (ysterectomy

route+ oerati8e time F>t(

ercentile 149 minutes:+ A$A class

#+ /iabetes mellitus+ an/ obesity

category M5+ 40 *gIm":. =e /i/

not Kn/ smo*ing status or (ysterec

tomy for gynecologic cancer to be

in/e en/ent ris* factors for

ostoerati8e cellulitis.

Our Kn/ing of t(e /ecrease/

occur rence of suerKcial $$5 aftert(e 8aginal aroac( for (ysterectomy

reafKrms t(e longareciate/ role for

8aginal (yster ectomy as t(e route of

c(oice for (yster ectomy.141

)aarotomy in/een/ently increase/

t(e ris* of suerKcial $$5 after(ysterectomy. A tren/ 'as seen for

increase/ $$5 'it( trocar incisions

minimally in8asi8e (ysterectomies:+

but t(is 'as not statistically signiKcant.

Our Kn/ings a// to re8ious

'or* 'it( National 2ealt(care $afetyNet'or* N2$N: /ata to eamine

$$5."+1

(e N2$N is an internet

base/ sur8eillance systemt(at isuse/by t(e 3,3 to monitor (osital

acuire/ infections t(at inclu/e $$5.1

Originally+ t(e N2$Nbase/ ris*

7/24/2019 Pi is 0002937813006261

11/17

A)E >

,emogra&(ic an/ clinical c(aracteristics of #0/ay ostoerati8e urinary tract infection after (ysterectomynC 1#+"":

Variable;rinary tract infectionnC 40":

No urinary tractinfection nC 1#+4"0: % 8alue

Age+ n B: .1

R0 y #9" 9.>: 1#+"04 9.4B:

0 y 10 ".>: "1 1.B:

!ace6 '(ite+ n B: ">9 4.4: 1#> 0.B: .1#

Et(nicity6 2is&anic+ n B: > 14.": "1>0 1.0B: .#

,iabetes mellitus+ n B: "# >.: 1000 .>: ."1

2istory of cerebro8ascular acci/ent 'it( neurologic/eficit+ n B:

1.>: 0 0.>: .01

3urrent smo*er+ n B: 90 "".4: "#" 19.: .1

o/y mass in/e .4"

R#0 *gIm"

"1> >#.>: 41 >>.:

#0 an/ R40 *gIm"

14 #.: 4491 ##.>:

40 *gIm"

40 10.0: 14 10.9:

Ascites+ n B: " 0.>: 10 0.: .

;nintentional 'eig(t loss+ n B:a

4 1.0: " 0.>: .1#

unctional status6 /e&en/ent for acti8ities of /ailyli8ing+ n B:

1.>: 9# 0.: .0

2ysterectomy for gynecologic cancer+ n B: " .>: .>: 1.00

%reo&erati8e anemia6 (ematocrit 9R#B:+n B: 9 "0.: "94> "".9: .#"

%reo&erati8e creatinine F1.>mgI/)+ n B: # 1.": > 0.9: .>1

American $ociety of Anest(esiologists class #+ n B: 99 "4.: ">1> 1.: R .01

5ntrao&erati8e bloo/ transfusion+ n B: 9 ".": ##> ".>: .

=or* relati8e 8alue unitb

1.1 #. 1.# #. .##

O&erati8e time6 F>t(&ercentile /uration+ n B: 1># #.1: ##1 "4.: R .001

y&e of anest(esia6 general+ n B: #9# 9.: 1"+9#9 9.4: .1

=oun/ class+ n B: .

13lean 0 ## 0.#:

"3leanIcontaminate/ #9 99.0: 1#+"0 9.:

#3ontaminate/ # 0.: 94 0.:

4,irty 1 0.#: ## 0.#:

a)oss of 10B or more of bo/y 'eig(t in t(e &re8ious mont(s not because of eercise or /ieting-

b,ata are gi8en as mean $,.

)a*e. $urgical site infections after (ysterectomy. Am J Obstet Gynecol "01#.

a/7ustment for all $$5 'as base/ on t(e

re/icti8e mo/el of 3ul8er et al11

t(at

incororate/ 'oun/ classiKcation+

A$A classiKcation+ an/ oerati8e time.;sing t(ese ris* factors+ E/'ar/s et al

"

analyHe/ nearly 000 (ysterectomies

t(at 'ere reorte/ to t(e N2$N.

(e occurrence of all ostoerati8e

$$5 suerKcial+ /ee

an/ organsace: after V2 'as 0.9B

an/ after A2 'as 1.B. ;nli*e t(e

reorts by 3ul8er et al an/ E/'ar/s et al+

our stu/y soug(t to i/entify ris* factorsfor $$5 t(at are more seciKc to (ysterectomy. y eamining 8arious ossible

7/24/2019 Pi is 0002937813006261

12/17

ris* factors+ our stu/y suggests a//itional

ris* factors+ suc( as route of

(ysterectomy+

&reo&erati8e anemia+ smo*ing status+

an/ (istory of 3VA t(at s(oul/ be

consi/ere/ in future stu/ies t(at

eamine $$5 after (ysterectomy.

Our Kn/ings are base/ on multi

institutional /ata t(at 'ere

collecte/ in a stan/ar/iHe/ fas(ion.

Olsen et al#erforme/ a multicenter

retrosecti8e

7/24/2019 Pi is 0002937813006261

13/17

A)E

)ogistic regression mo/el for association of urinary tract infection after(ysterectomy

A/7uste/

of t(e incision at t(e 8aginal cuff.

After a (ysterectomy+ an eamle of a

/ee $$5 'oul/ be consi/ere/ a

8aginal cuff abscess. =e belie8e t(at a

&el8ic abscess t(at /rains t(roug( t(e

8aginal cuff+

Variable2istory of cerebro8ascularacci/ent 'it( neurologic /eficit

o//s ratio 9>B 35 % 8alue#."9 1.41e.0 R .01

'(ic( 'oul/ be consi/ere/ as a /eesace $$5 /raining t(roug( t(esurgical incision+ is essentially similar

to a el8ic

3urrent corticosteroi/ use ".# 1.14e4.90 .0"

O&erati8e time F>t(&ercentile /uration 1. 1.>"e"."9 R .001

35+confi/ence inter8al.

)a*e. $urgical site infections after (ysterectomy. Am J Obstet Gynecol "01#.

abscess t(at reuires /rainage t(roug(

inter8entional ra/iology+ '(ic( alter

nati8ely 'oul/ be categoriHe/ as an

organsace $$5. ecause of t(e o8erla

bet'een t(ese terms+ 'e electe/ to

combine /ee an/ organsace $$5.

(e ris* factors associate/ 'it(&ost

casecontrolle/ stu/y 'it( a&&roi

mately 00 atients after A2 an/V2. (e cases an/ control sub7ects

'ere collecte/ 'it( t(e use of t(e

5nternational 3lassiKcation of,iseases+ Nint( !e8i sion+ 3linical

Mo/iKcation &roce/ure co/es for

(ysterectomy from 4 artici ating

3,3 %re8ention Eicenter %ro gram

(ositals from "00#"00>. ot( M5

F#> *gIm"

an/ intraI&ostoerati8e

bloo/ transfusion 'ere i/entiKe/ as

in/een/ent ris* factors for suerKcial

$$5 after (ysterectomy 'it(laarotomy. $imilarly+ a singleinstitution c(art re8ie' also foun/

obesity M5+ #0 *gIm": an/ bloo/

transfusion re+ intra+ an/

ostoerati8e: to be associate/ 'it( all

$$5 after ab/ominal (ysterectomy.4

2o'e8er+ ot(ers (a8e foun/ obesity

not to be a ris* factor for

osto&erati8e comlications after

gynecologic sur gery.19

=e foun/

t(at+ by consi/ering M5 F#0 *gIm"+

M5 'as i/entiKe/ as a ris*factor forsu&erKcial $$5 cellulitis:. 5n our larger

multicenter analysis+ 'e /i/ not Kn/ an

associationbet'een&re oerati8etransfusion an/ $$5. Alt(oug(

intraoerati8e transfusion 'as i/entiKe/

in our bi8ariate analysis to be associate/

'it( cellulitis an/ /eeIorgansace $$5+'e /i/ not Kn/ a statistically signiKcant

association bet'een intraoerati8e

trans fusion an/ $$5 after a/7usting

for ot(er 8ariables. (e /ifferences in

our Kn/ings an/ re8ious reortsregar/ing trans fusion bot( re an/

intraoerati8e: as a ris* factor for $$5

after (ysterectomy li*ely are relate/ to

t(e robust sam&le siHeof our

stu/y.

=e i/entiKe/ ris* factors t(at

'ere associate/ 'it( /ee an/

organs&ace

$$5 after (ysterectomy t(at inclu/e/

&reo&erati8e anemia an/ (istory of 3VA+'(ic( may be reecti8e of c(ronic &re

oerati8e systemic /isease. (ese ris*

factors are in a//ition to ris* factors of

A$A class #+ current smo*ing status+

an/ morbi/ obesity M5+ 40 *gIm":.

=e /i/ not Kn/ a statistically signiKcant

/ifference in /ee an/ organsace $$5

bet'een /ifferent (ysterectomy routes.

=e (yot(esiHe t(at our Kn/ings of

increase/ association of bot( &reo&era

ti8e anemia an/ (istory of 3VA 'it(

/ee an/ organsace $$5 may reect a/ecrease of t(e bo/ySs ability to res&on/to stressors of surgery an/ to combat

ostoerati8e infection. =e foun/ an

association bet'een reoerati8e 3VA

'it( resi/ual neurologic /eKcit an/ t(e

ris* of /ee an/ organsace $$5. 3VA

(as been note/ to be associate/ signiK

cantly 'it( any a/8erse ostoerati8e

e8ent."0

=e belie8e t(at 'e may (a8e

obser8e/ t(is relations(i because 3VA

'it( resi/ual neurologic /eKcit is a ris*

factor for functional /een/ence.

"1

3(enet al

""foun/ functional /een/ence to

be an in/een/ent ris* factor for &ost

oerati8e $$5+ seciKcally met(icillin

resistant $ta&(ylococcus aureus $$5+ in

ol/er a/ults.

=e /i/ not Kn/ /ifferences in ris*

factors for /ee an/ organsace $$5

'(en 'e eamine/ t(ese infections se

arately. =e ultimately c(ose to combine

t(ese " categories '(en eamining

$$5 after (ysterectomy. =e belie8e t(at

/ee an/ organsace $$5+ alt(oug(/eKne/ /istinctly by t(e A3$ N$?5%

an/ 3,3 criteria+ are functionally t(e

7/24/2019 Pi is 0002937813006261

14/17

same e8ent after (ysterectomy because oerati8e ;5 after (ysterectomy 'ere

a (istory of 3VA 'it( neurologic

/eKcit+ c(ronic steroi/ use+ an/

oerati8e time F>t( ercentile. =e

foun/ t(e occurrence of #0/ay

ostoerati8e ;5 'as #.0B n @

40" 'omen: after (ys terectomy.

;nfortunately+ 'e /i/ not (a8e

information on cat(eter use or

/urationbecause of limits of t(e/ataset. One (un/re/ fortyt'o

'omen 'ere i/entiKe/ as (a8ing

reoerati8e sys temic infection

t(at inclu/e/ se&sis+ se&tic s(oc*+

an/ systemic inammatory resonse

syn/rome an/ 'ere eclu/e/because

of t(e in(erent /ifference in t(ese

cases from 'omen '(o un/ergo

sc(e/ule/ electi8e surgery.

Alt(oug( t(ese con/itions may be

associate/ 'it( a greater ris* of

ostoerati8e $$5+ t(e small numbersan/ t(e 8arious /ifferent causes of

systemic infection ma/e it /ifKcult

to /ra' conclusions in t(e cur

rent stu/y.

Our stu/y (as many limitations.

(e Krst is t(at our analysis 'as

limite/ to t(e 8ariables t(at eiste/ in

t(e /atabase. or eamle+ 'e 'ere

limite/ by t(e A3$ N$?5%

/eKnition of /ee an/ organsace

$$5- t(erefore+ 'e 'ere also unable to

/istinguis( bet'een&el8ic ab scesses+8aginal cuff cellulitis+ or fasciitis.

$econ/+ seciKc 8ariables 'ere not

collecte/ in t(e general A3$N$?5% /ataset t(at 'oul/ (a8e

en(ance/ our stu/y Kn/ings. or

eamle+ t(e ty&e an/ timing ofreoerati8e&ro&(ylactic antibiotic

a/ministration+ '(ic( is a factor

lin*e/ to ostoerati8e infec

tion+"#+"4

'ere not a8ailable in t(e

/atabase. Anot(er limitation of t(is

/ataset 'as t(e lac* of informationabout t(e

7/24/2019 Pi is 0002937813006261

15/17

4

A)E

A

ll#0/ay&osto&erati8esurgical

siteinfectionsan/urinarytractinfectionsby(ysterectomyroute

n

C

1#+G

"":

4otalab/ominal

(ysterectomy+

nB

:

>0E9

9#.G

:

141

".E

:

E

1."

:

1"G

".4

:

$u&racer8ical

(ysterectomy+

nB:

EGG94

.0:

1"

.#:

G1

.1:

19"

.E:

4otal8aginal

(ysterectomy+

nB:

"9"19>.#

:

10

.E:

#"1

.0:

94#

.1:

)a&arosco&icassiste/

8aginal

(ysterectomy+n

B:

"09494.#

:

10

.:

##1

.>:

E#

.4:

4otalla&arosco&ic

(ysterectomy+

nB:

G#9>."

:

>0

.E:

40

.>:

###.G

:

)a&

arosco&ic

su&racer8ical

(ysterectomy+nB:

14

"9E.

:

"

01

.#:

100

.:

"01

.#:

4y&eo

fsurgical

siteinfection

None3

ellulitis

,ee&Io

rgan0s&ace

;rinary

tract

infection

n 1#

+01

94

.E:

"11

.E:

1>41

.1:

#0"

.:

)a*e.

$urgicalsiteinfectionsafter(ysterectomy.

Am

JObstetG

ynecol"01#.

in/ication for (ysterectomy. $urgical

roce/ures 'ere categoriHe/ by 3%

co/es alone. (e occurrence of &ost

oerati8e ;5 after rolase or anti

incontinence surgery (as been re&orte/

to be (ig(er t(an t(at foun/ in our

stu/y.">

ecause t(e 'omen 'ereselecte/ for inclusion in t(is stu/y base/

on (ysterectomy an/ not rolase or

incontinence roce/ures+ 'e 'ere not

able to /etermine t(e occurrence of

;5 after rolase or incontinence&ro

ce/ures in our current analysis.

=e /i/ not Kn/ an association 'it(

(ysterectomies t(at 'ere erforme/

for gynecologic cancer an/ $$5 base/

on 3%4 co/es. (is Kn/ing may also

be /ue to t(e lac* of s&eciKc

information in t(e /ataset regar/ingcancer stage+ gra/e+ an/ at(ologic

con/ition in t(e A3$ N$?5% /ataset.

=e 'ere limite/ to t(e i/entiKcation of

roce/ures for gyneco logic cancer

base/ on 3%4 co/es t(at in/icate/

ra/ical /issection an/ lym(a

/enectomies. A//itionally+ some

(yster ectomies for cancer t(at

reuire/ bo'el resection may (a8e

been co/e/ rimarily as colon surgery

an/ t(erefore not inclu/e/ in our

analysis. =e /i/ eamine all cancer8ariables t(at 'ere a8ailable in t(e

A3$ N$?5% /ataset inclu/ing *no'n

/isseminate/ tumor+ c(emo t(eray+

or ra/iation t(eray 'it(in

#0 /ays before roce/ure an/ *no'n

central ner8ous system tumor: bot(

in/i8i/ually an/ as a comosite grou&

an/ /i/ not Kn/ a statistically

signiKcant association 'it( $$5. (is+

again+ li*ely reects t(e limitation of

t(e /ataset because it /oes not inclu/e

cancer stage+ gra/e+ an/ /isease.

)ast+ (osital articiation in t(e

A3$ N$?5% is 8oluntary an/ conK/en

tial+ '(ic( may intro/uce selectionbias-

(o'e8er+ as of "009+ F#"0 (os&itals

'ere articiating in t(e A3$ N$?5%

&ro gram+ '(ic( inclu/e/ a 'i/e

range of community (ositals an/

tertiary care centers. (e A3$ N$?5%

&artici&antuse /ata Kles /o not allo'

for i/entiKcation of articiating

(ositals 'it(in t(e /ataset- t(erefore+

'e 'ere not able to account for t(e

effect of clustering of obser8ations'it(in centers. 2o'e8er+ re8ious

in8

est

iga

tor

s

(a

8e/e

mo

n

str

ate

/

t(a

t

t(e

clu

ste

ring

eff

ect

fro

m

t(e

7/24/2019 Pi is 0002937813006261

16/17

A$3 N$?5% for ot(er en/oints is minimal an/ /i/ not c(ange t(e o8erall

a/7uste/ outcomes.>+"

Our stu/y suggests t(at numerous factors+ '(ic( inclu/e (ysterectomy route+

oerati8e time+ /iabetes mellitus+ A$A class #+ M5+ smo*ing status+ &re

oerati8e anemia+ 3VA 'it( neurologic /eKcit+ an/ corticosteroi/ use are associ

ate/ 'it( $$5 after (ysterectomy. ,e8el oment of a &re/icti8e mo/el for $$5

after all tyes of (ysterectomy is nee/e/. ;nfortunately+ 'e cannot /e8elo a

&re /icti8e mo/el 'it( t(is current 'or* because of a lac* of a 8ali/ation

co(ort.

,ecreasing re8entable (os&ital acuire/ infections is imortant for t(esa*e of uality atient care. 5n lig(t of t(e recent national 3M$ man/ate t(at

reuires all Me/icarecertiKe/ (ositals to reort /ata an/ outcome measures

&ublicly+ t(e re8ention of $$5 'ill soon become imortant for a (ositalSs

Knancial stability as 'ell.1

(e A3$ N$?5% rogram to imro8e uality an/

atient safety (as succee/e/ by &ro 8i/ing timely+ consistent+ conK/ential+

ris*a/7uste/ fee/bac* to articiating institutions on t(e institutional occur

rence of a 'i/e range of ostoerati8e comlications.>

5nstitutions imme/i ately

can i/entify systems an/ strategies to imro8e atient outcomes in outlying areas.>

(is conK/ential ris*a/7uste/ rogram (as begun to imro8e surgical outcomes.

no'le/ge of t(e baseline occurrence of ostoerati8e $$5 after /ifferent

routes of (ysterectomy an/ associate/ ris* factors is imortant to imro8e

atient safety after (ysterec tomy by (eling to i/entify mo/iKable factors to

re8ent $$5. ecause 3M$ enforces man/atory ublic re&orting of

ostoerati8e $$5 after (ysterec tomy 'it(out ris* a/7ustment seciKc to

(ysterectomy+ careful monitoring must be use/ to i/entify uninten/e/conseuences. 0

!EE!EN3E$

1. 3enters for Me/icare an/ Me/icai/ $er8ices 3M$:+ 22$. inal rule 3M$ 149. fe/eral

register 8olume >+ number 1> Mon/ay+ august

1+ "010:DCrules an/ regulationsD Cages >0041

>0D from t(e fe/eral register online 8ia t(e go8ernment &rinting ofKce C' ' ' .g& o .g o8D

http://www.gpo.gov/http://www.gpo.gov/http://www.gpo.gov/http://www.gpo.gov/http://www.gpo.gov/http://www.gpo.gov/http://www.gpo.gov/

7/24/2019 Pi is 0002937813006261

17/17

C! /oc no6 "0101909". A8ailable at6( tt& 6II

'''.g&o.go8If/sysI&*gI!"01101I(tmlI

" 0 1 1 1 9 1 9 .( tm. Accesse/ ,ec. 19+

"01".

". E/'ar/s J!+ %eterson ,+ An/rus M)+ et al.

National (ealt(care safety net'or* N2$N:

reort+ /ata summary for "00 t(roug( "00.

Am J 5nfect 3ontrol "00-#6 0 9" .

#. Olsen MA+ 2ig(am essler J+ 9 #.

. National 5nstitutes of 2ealt(. 3linical gui/e

lines on t(e i/entiKcation+ e8aluat ion+ an/ treat

ment of o8er'eig(t an/ obesity in a/ults6 t(e

e8i/ence reort. Obes !es 199-su l ":6

>1$"09 $.

. =u =3+ $c(ifftner )+ 2en/erson =G+ et al.

%reoerati8e (ematocr it le8els an/ &ost

oerati8e outcomes in ol/er atients un/ergoing

noncar/iac surgery. JAMA "00-"9 6"41 .

9. 2 eisler 3 A + A le t ti G,+ =e a 8er A )+

M e lt on )J # r /+ 3l i by =A+ Ge b (art J. 5m r o8 i ng

u ality of ca r e6 /e 8 e l o& m ent of a ris *a /7ust e /e r io er a ti 8e mor bi/i ty mo / el f o r 8a gin al (y s

te r ec t om y . A m J O b s te t Gy n ecol "0 10 -"0 "6

1# .e1 >.

10. ,o'/y $3+ ora( J+ a**umG a meH JN+

et al. actors re/icti8e of &osto&e rati8e

morbi/ity an/ cost in atients 'it( en/ome trial

cancer. Obstet Gynec o l"01"-1"06 1419" .

11. 3ul8er ,2+ 2oran 3+ Gaynes !%+ et al.

$urgical 'oun/ infection rates by 'oun/ class+

oerati8e &roce/ure+ an/ atient ris* in/e6

National Nosoc o mial 5nfectio n s $ur8eillance$ystem. Am J Me/ 1991-916 1>"$ $.

1". American 3ollege of $urgeons National

$ur gical ?uality 5mro8ement %rogram.

%artici&ant use /ata Kle. A8ailable at6

( tt& 6IIsite .ac sn s i&.o rgI &a r tici&a ntu s e /a ta

KleI. Accesse/ Aug. 1>+

"01".

1#. 2oran 3+ An/rus M+ ,u/ec* MA. 3,3I

N2$N sur8eillan c e /eKnition of (ealt( care

associat e / infection an/ criteria for s&eciKc

tyes of infections in t(e acute care setting. Am J

5nfect 3ontrol "00-#6# 0 9#".

14. o8a c $ ! . G u i/ e line s to /etermin e t( eroute

o f ( y st ere c to m y . Ob st e t Gy necol 19 9 >- >61 " #.

1>. alc on e + = alt e r s M, . 2 y ster e cto m y fo r

b e n ig n /is ease. O b st e t G yne col

" 0 0-1 11 6 > # .

1. American 3ollege of Obstetri c ians an/ Gy

necologi s ts. A3OG committee oinion no. 4446

c(oosing t(e route of (ysterect o my for benign

/isease. Obstet Gynecol "009-1146 1 1>.

1. Mu + "01".

19. 3(en 33+ 3ollins $A+ !o/gers A+

%araiso M+ =alters M,+ arber M,.

%erioera ti8e comli c ations in obese 'omen 8s

normal'ei g (t 'omen '(o un/ergo 8aginal

surgery. Am J Obstet Gynecol "00- 1 969.

e1.

"0. )iu ))+ )eung JM. %re/icting a/8erse

&osto&erat i8e outcom e s in atients age/ 0

years or ol/er. J Am Geriatr $oc "000-46

40>1 ".

"1. ernan / es G+ Goulart A3+ $antosJunior =!+ Alencar A%+ ensenor 5M+ )otufo %A.

E/ucational le8els an/ t(e function al /e&en

/ence of isc(emic stro*e sur8i8ors. 3a/ $au/e

%ublica "01"-"61 > 190.

"". 3(en