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Background Colorectal surgical procedures place substantial burden on health care systems because of the high complication risk, of surgical site infections in particular. The risk of surgical site infection after colorectal surgery is one of the highest of any surgical specialty. Objective The purpose of this study was to determine the incidence, cost of infections after colorectal surgery, and potential economic benefit of using antimicrobial wound closure to improve patient outcomes. Design Retrospective observational cohort analysis and probabilistic cost analysis were performed. Settings The analysis utilized a database for colorectal patients in the United States between 2014 and 2018. Patients A total of 107,665 patients who underwent colorectal surgery were included in the analysis. Main outcome measures Rate of infection was together with identified between 3 and 180 days postoperatively, infection risk factors, infection costs over 24 months postoperatively by payer type (commercial payers and Medicare), and potential costs avoided per patient by using an evidence-based innovative wound closure technology. Results Surgical site infections were diagnosed postoperatively in 23.9% of patients (4.0% superficial incisional and 19.9% deep incisional/organ space). Risk factors significantly increased risk of deep incisional/organ-space infection and included several patient comorbidities, age, payer type, and admission type. After 12 months, adjusted increased costs associated with infections ranged from $36,429 to $144,809 for commercial payers and $17,551 to $102,280 for Medicare, depending on surgical site infection type. Adjusted incremental costs continued to increase over a 24-month study period for both payers. Use of antimicrobial wound closure for colorectal surgery is projected to significantly reduce median payer costs by $809 to $1170 per patient compared with traditional wound closure. Limitations The inherent biases associated with retrospective databases limited this study. Conclusions Surgical site infection cost burden was found to be higher than previously reported, with payer costs escalating over a 24-month postoperative period. Cost analysis results for adopting antimicrobial wound closure aligns with previous evidence-based studies, suggesting a fiscal benefit for its use as a component of a comprehensive evidence-based surgical care bundle for reducing the risk of infection. See Video Abstract at http://links.lww.com/DCR/B358. EVALUACION DEL RIESGO Y LA CARGA ECONOMICA DE LA INFECCION DEL SITIO QUIRURGICO DESPUES DE UNA CIRUGIA COLORRECTAL UTILIZANDO UNA BASE DE DATOS LONGITUDINAL DE EE.UU.: ?EXISTE UN PAPEL PARA LA TECNOLOGIA INNOVADORA DE CIERRE DE HERIDAS ANTIMICROBIANAS PARA REDUCIR EL RIESGO DE INFECCION?: Los procedimientos quirurgicos colorrectales suponen una carga considerable para los sistemas de salud debido al alto riesgo de complicaciones, particularmente las infecciones del sitio quirurgico. El riesgo de infeccion posoperatoria del sitio quirurgico colorrectal es uno de los mas altos de cualquier especialidad quirurgica.El proposito de este estudio fue determinar la incidencia, el costo de las infecciones despues de la cirugia colorrectal y el beneficio economico potencial del uso del cierre de la herida con antimicrobianos para mejorar los resultados de los pacientes.Analisis retrospectivo de cohorte observacional y analisis de costo probabilistico.El analisis utilizo la base de datos para pacientes colorrectales en los Estados Unidos entre 2014 y 2018.Un total de 107,665 pacientes sometidos a cirugia colorrectal.Se identifico una tasa de infeccion entre 3 y 180 dias despues de la operacion, los factores de riesgo de infeccion, los costos de infeccion durante 24 meses posteriores a la operacion por tipo de pagador (pagadores comerciales y Medicare), y los costos potenciales evitados por paciente utilizando una tecnologia innovadora de cierre de heridas basada en evidencias.Infecciones del sitio quirurgico, diagnosticadas postoperatoriamente en el 23,9% de los pacientes (4,0% incisional superficial y 19,9% incisional profunda / espacio organico). Los factores de riesgo aumentaron significativamente el riesgo de infeccion profunda por incision / espacio organico e incluyeron comorbilidades selectivas del paciente, edad, tipo de pagador y tipo de admision. Despues de 12 meses, el aumento de los costos asociados con las infecciones vario de $ 36,429 a $ 144,809 para los pagadores comerciales y de $ 17,551 a $ 102,280 para Medicare, segun el tipo de infeccion del sitio quirurgico. Los costos incrementales ajustados continuaron aumentando durante un periodo de estudio de 24 meses para ambos pagadores. Se preve que el uso del cierre antimicrobiano de la herida para la cirugia colorrectal reducira significativamente los costos medios del pagador en $ 809- $ 1,170 por paciente en comparacion con el cierre tradicional de la herida.Los sesgos inherentes asociados a las bases de datos retrospectivas limitaron este estudio.Se encontro que la carga del costo de la infeccion del sitio quirurgico es mayor que la reportada previamente, y los costos del pagador aumentaron durante un periodo postoperatorio de 24 meses. Los resultados del analisis de costos para la adopcion del cierre de heridas antimicrobianas se alinean con estudios previos basados en evidencia, lo que sugiere un beneficio fiscal para su uso como componente de un paquete integral de atencion quirurgica basada en evidencia para reducir el riesgo de infeccion. Consulte Video Resumen en http://links.lww.com/DCR/B358.

The conventional view of 'Duncan v Cammell Laird' was succinctly expressed by Wade and Forsyth. "The case", they wrole: "is a good example of the most genuine type where it seems plain that the interests of litigants must be sacrificed in order to preserve secrets of state." To Zuckerman Duncan was "the most outstanding" example of a rare number of cases genuinely involving national security. These, along with almost all other commentators, argue that national security considerations meant that the 1942 decision was on its facts pretty well inevitable and probably correct. This article suggests thal the view that the plaintiffs had to take second place to the greater good of keeping Germany in ignorance of British naval secrets perpetuates a myth. This myth was fostered by civil sewice lawyers in the interesis of litigation management by the Crown. The case papers tell a different story.

Background:. The U.S. Patient Protection and Affordable Care Act created the Hospital Readmissions Reduction Program (HRRP) and the Hospital-Acquired Condition Reduction Program (HACRP). Under these programs, hospitals face reimbursement reductions for having high rates of readmission and hospital-acquired conditions. This study investigated whether readmission following total joint arthroplasty (TJA) under the HRRP was associated with reimbursement penalties under the HACRP. Methods:. Hospital-level data on hospital-acquired conditions, readmissions, and financial penalties were obtained from Definitive Healthcare. Outcomes included receipt of an HACRP penalty and the associated losses in revenue in 2018. Logistic regression and linear regression models were used to determine whether the all-cause, 30-day readmission rate following TJA was associated with the receipt or magnitude of an HACRP penalty. Results:. Among 2,135 private, acute care hospitals, 477 (22.3%) received an HACRP penalty. After controlling for other patient and hospital characteristics, hospitals with a 30-day readmission rate of >3% after TJA had over twice the odds of receiving an HACRP penalty (odds ratio, 2.20; p = 0.043). In addition, hospitals with a readmission rate of >3% after TJA incurred $77,519 more in revenue losses due to HACRP penalties (p = 0.011). These effects were magnified in higher-volume hospitals. Conclusions:. Acute care hospitals in the United States with higher 30-day readmission rates following TJA are more likely to be penalized and to have greater revenue losses under the HACRP than hospitals with lower readmission rates after TJA. This strengthens the incentive to invest in the prevention of readmissions after TJA, for example, through greater efforts to reduce surgical site infections and other modifiable risk factors.

The global push to combat the problem of antimicrobial resistance has led to the development of antimicrobial stewardship programs (ASPs), which were recently mandated by The Joint Commission and the Centers for Medicare and Medicaid Services. However, the use of topical antibiotics in the open surgical wound is often not monitored by these programs nor is it subject to any evidence-based standardization of care. Survey results indicate that the practice of using topical antibiotics intraoperatively, in both irrigation fluids and powders, is widespread. Given the risks inherent in their use and the lack of evidence supporting it, the practice should be monitored as a core part of ASPs, and alternative agents, such as antiseptics, should be considered.

Environmental disinfection has become the new frontier in the ongoing battle to reduce the risk of health care-associated infections. Evidence demonstrating the persistent contamination of environmental surfaces despite traditional cleaning and disinfection methods has led to the widespread acceptance that there is both a need for reassessing traditional cleaning protocols and for using secondary disinfection technologies. Ultraviolet-C (UV-C) disinfection is one type of no-touch technology shown to be a successful adjunct to manual cleaning in reducing environmental bioburden. The dilemma for the infection preventionist, however, is how to choose the system best suited for their facility among the many UV-C surface disinfection delivery systems available and how to build a case for acquisition to present to the hospital administration/C-suite. This article proposes an approach to these dilemmas based in part on the experience of 2 health care networks.

Background A growing body of research has demonstrated that manual cleaning and disinfection of the operating room (OR) is suboptimal. Residual environmental contamination may pose an infection risk to the surgical wound. This study evaluates the impact of a visible-light continuous environmental disinfection (CED) system on microbial surface contamination and surgical site infections (SSI) in an OR. Methods Samples from 25 surfaces within 2 contiguous ORs sharing an air supply were obtained after manual cleaning on multiple days before and after a visible-light CED system installation in 1 of the ORs. Samples were incubated and enumerated as total colony-forming units. SSIs in both ORs, and a distant OR, were tracked for 1 year prior to and 1 year after the visible-light CED system installation. Results There was an 81% (P = .017) and 49% (P = .015) reduction in total colony-forming units after the visible-light CED system installation in the OR in which the system was installed, and in the contiguous OR, respectively. In the OR with the visible-light CED system, SSIs decreased from 1.4% in the year prior to installation to 0.4% following installation (P = .029). Conclusions A visible-light CED system, used in conjunction with manual cleaning, resulted in significant reductions in both microbial surface contamination and SSIs in the OR.

Efforts to reduce health care–associated infections (HAIs) have grown in both scale and sophistication over the past few decades; however, the increasing threat of antimicrobial resistance and the impact of new legislation regarding HAIs on health care economics make the fight against them all the more urgent. On-demand polymerase chain reaction (PCR) technology has proven to be a highly effective weapon in this fight, offering the ability to accurately and efficiently identify disease-causing pathogens such that targeted and directed therapy can be initiated at the point of care. As a result, on-demand PCR technology has far-reaching influences on HAI rates, health care outcomes, hospital length of stay, isolation days, patient satisfaction, antibiotic stewardship, and health care economics. The basics of on-demand PCR technology and its potential to impact health care have not been widely incorporated into health care education and enrichment programs for many of those involved in infection control and prevention, however. This article serves as a primer on on-demand PCR technology and its ramifications.

Background: Perioperative hair removal using clippers requires lengthy cleanup to remove loose hairs contaminating the operative field. We compared the amount of hair debris and associated microbiologic contamination produced during clipping of surgical sites using standard surgical clippers (SSC) or clippers fitted with a vacuum-assisted hair collection device (SCVAD). Methods: Trained nurses conducted bilateral hair clipping of the chest and groin of 18 male subjects using SSC or SCVAD. Before and during clipping, measurements of particulate matter and bacterial contamination were evaluated on settling plates placed next to each subject’s chest and groin. Skin condition after clipping and total clipping/cleanup times were compared between SSC and SCVAD. Results: The microbial burden recovered from residual hair during cleanup in the SSC group was 3.9 log10 CFU and 4.6 log10 CFU from respective, chest, and groin areas. Use of the SCVAD resulted in a significant (P < .001) reduction in both residual hair and microbial contamination within the operative field compared with SSC. Conclusions: Use of SCVAD resulted in significant (P< .001) reduction in total time required to clip and clean up residual hair contaminating the operative field compared with standard practice (ie, SSC), eliminating the need to physically remove dispersed hairs, which can harbor a significant microbial burden, from within the operative field.

The article, based on a review of files in the National Archives, examines the role of civil servants in claims for the suppression of state documents at trial on grounds of public interest immunity (PII). Government lawyers solicited responses from other ministries to the landmark Lords decision in Conway v. Rimmer and coordinated the civil service campaign against this unwelcome judicial intrusion into their professional domain. The decision was seen as a threat to confidentiality and the secret cultivation of administrative expertise. Academic debate on the evolution of the PII doctrine has centred on the allocation of responsibility between an overly deferential judiciary and ministerial concern to avoid political embarrassment. The role of civil servants may have been more coherent and ideologically motivated than previously appreciated. As the courts increasingly challenge government claims for suppression of material at trial, the article highlights the historical factors determining the executive's innate instinct for secrecy.

'In modern Britain', writes Robert Stevens, 'the concept of the separation of powers is cloudy and the notion of the independence of the judiciary remains a term of constitutional rhetoric. Certainly its penumbra and perhaps even its core are vague.' Stevens himself contributed enormously to shedding light on this constitutional tenet as it has operated over the last one hundred years by his detailed and painstaking historical research conducted primarily in the papers of the Lord Chancellor's Office.1 However, Stevens draws on a somewhat limited range of official archives. The suggestion made here is that constitutional law scholars can gain further insights into the relationship between the executive and the judiciary by researching more widely in the National Archives in the Cabinet, Departmental, and Prime Ministerial papers. These provide a rich source of instances of the political interface between ministers and senior judges and add considerable detail to the often more abstract doctrinal constitutional law texts.2 Such research can also suggest new and unexpected aspects of constitutional doctrine, in particular, that of the separation of powers. One example of this empirical approach is recently published research into the operation of the hugely controversial and short-lived Industrial Relations Act 1971.3 Independence is an essential attribute of the modern judiciary, jealously guarded and held by many to be the key safeguard against abuse of executive

To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection.To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation.A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4%, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4%, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance.Preadmission showers using chlorhexidine gluconate, 4%.The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4%, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4%; duration (number of showers); and timing (pause) before rinsing.The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses.A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.

The recent opening under the 30-year rule of official papers concerning the Industrial Relations Act 1971 makes it possible to reappraise the conventional view of this short-lived statute and also more general implications of the process of policy making at a time of acute political crisis. The papers shed new light on the relationship between the government and the judiciary, in particular the President of the National Industrial Relations Court, Sir John Donaldson. They provide empirical evidence of how the judicial and political arms of government dealt with social and industrial upheavals and they prompt reflections on the nature of the separation of powers in the United Kingdom's constitutional arrangements. It is argued that, in examining the nature and extent of judicial independence, constitutional law scholars have hitherto concentrated on executive influence on the judiciary and tended to ignore the extent to which judges may secretly influence politicians.