Abstract
Background:
Earlier a randomized trial showed efficacy of a multifaceted intervention approach for reducing surgical site infection: hand hygiene, vascular care, environmental cleaning, patient decolonization (nasal povidone iodine, chlorhexidine wipes), with feedback on pathogen transmission. The follow-up prospective observational study showed effectiveness when applied to all operating rooms of an inpatient surgical suite. In practice, many organizations will at baseline not be using conditions equivalent to the control groups but instead functionally have had ongoing a single intervention for infection control (e.g., encouraging better hand hygiene). Organizations also differ in how well and long they survey every surgical patient for postoperative surgical site infection. Thus, estimation of the expected net cost savings from implementing multifaceted intervention depends on the relative efficacy of multifaceted approach versus single intervention approaches and on the incidence of surgical site infection, the latter depending itself on the monitoring period for infection development.
Methods:
The retrospective cohort analysis included 4,865 patients from two single intervention and two multifaceted studies, each of the four studies with matched control groups. We used Poisson regression with robust variance to estimate the relative risk reduction in surgical site infections for the multifaceted approach versus single interventions and, with 30-day follow-up versus ≥60-day follow-up for infection.
Results:
The multifaceted approach was associated with an estimated 68% reduction in postoperative surgical site infections relative to single interventions (risk ratio 0.32, 97.5% confidence interval 0.15–0.70, P=.001). There were approximately 2.61-fold more surgical site infections detected with follow-up for at least 60 days of medical records relative to 30 days of records reviewed (97.5% CI 1.62 to 4.21, P <0.001).
Conclusions:
An evidence-based, multifaceted approach to anesthesia work area infection control can generate substantial reductions in surgical site infections. A follow-up period of at least 60-days is indicated for infection detection.
Keywords: Staphylococcus aureus, infection prevention, retrospective cohort study
1. Introduction
The intraoperative arena is a high-risk environment for bacterial transmission [1,2] where the most common major surgical complication, surgical site infection development, affects 2–5% of patients undergoing surgery, prolongs hospital duration and mortality, increases the risk of intensive care unit admission, and increases direct and indirect healthcare costs [3,4,5,6].
We have conducted several trials over the last decade to assess the efficacy of various approaches to attenuate intraoperative bacterial transmission and subsequent healthcare-associated infection development [7,8,9,10]. Important knowledge gaps include generating an understanding of the relative efficacy of single interventions [7,8] vs. a multifaceted approach (i.e., bundle plus feedback [1,9,10]) and the importance of duration of follow-up for surgical site infection development. The duration of follow-up in this context does not refer to the time course for infection to develop, rather time in routine US care for medical records (e.g., clinic notes) to contain information about the surgical site infections. Both results are needed for economic analyses because many organizations will at baseline not be using conditions equivalent to trial control groups but instead functionally using (disparate) single interventions for infection control (e.g., encouraging better hand hygiene). Estimation of the net cost savings from multifaceted intervention depends on the relative efficacy of multifaceted approach versus single intervention approaches and on the incidence of infection, that depending itself on the monitoring period at the hospital for all surgical patients.
The dual aims of this retrospective cohort study were to learn the relative efficacy of multifaceted vs. single intervention anesthesia work area preventive approaches to prevent surgical site infections and to assess the importance of patient follow-up for monitoring of surgical site infections.
2. Methods
The University of Iowa determined April 21, 2022, that this study #202204468 did not meet the definition of human subject’s research because it was limited to analysis of de-identified data.
We conducted a retrospective cohort analysis of aggregate data from four prospective studies that were conducted over the last decade and involved a total of 4,865 patients [7,8,9,10]. Two studies involved single interventions [7,8], and two studies involved an evidence-based, multifaceted approach involving feedback [9,10]. Studies involving single interventions included improved hand hygiene (N=3,256) [7] and vascular care (N=572) [8], both of which followed patients for 30 postoperative days for development of surgical site infection. Studies of the multifaceted approach involved implementation of hand hygiene, vascular care, environmental cleaning, and patient decolonization (nasal povidone iodine, chlorhexidine wipes) improvement strategies in parallel during the process of patient care in a randomized trial (N=236) [9] and in a post-implementation analysis (N=801) [10]. Both also included compliance feedback defined by measured reservoirs returning <100 colony forming units per surface area sampled (e.g., <100 colony forming units for an anesthesiologists’ hand sample to show adequate compliance with hand hygiene). Adult patients who underwent anesthesia according to usual care with single or multifaceted infection control interventions as described above and requiring of peripheral intravenous catheter placement were followed for 60 postoperative days for the randomized trial [9] and for 90 postoperative days for the post-implementation analysis [10]. Our dual primary analyses of aggregate patient-level data were designed to inform the relative efficacy of single vs. multifaceted approaches and the importance of duration of follow-up for prevention of surgical site infection.
Baseline infection control practices for each study included routine and terminal environmental cleaning with quaternary ammonium compounds ± surface disinfection wipes. All providers had access to alcohol dispensers located on the wall and/or anesthesia carts, and gloves were immediately available for use [1,7,8,9,10,11].
Surgical site infections were identified in each of the four studies by prospective chart review of the electronic medical record, including initial criteria of fever, white blood cell count, culture, office note documentation, and antibiotic order, and they were defined by National Healthcare Safety Network criteria [7,8,9,10,12].
All patients were followed by chart review for binary demographic information including American Society of Anesthesiologists [ASA] health classification status > 2, hospital admission before the day of surgery or urgent surgery, case duration > 2 hours, female sex of the patient, general abdominal surgery, orthopaedic surgery, and dirty or infected site, as well as patient age. The demographic variables collected in the studies were those potentially associated with surgical site infections and differing substantively among operating rooms [13].
For statistical analyses, individual patients’ surgical site infection results and demographic variables were combined among the four studies. Fisher’s exact tests with two-sided P-values were used to evaluate the associations of the above covariates and surgical site infection among the control groups, except for age where the Mann-Whitney test was used. Variables with calculated P <.10 were included in the multivariable model. The binary treatment variable equaled 1 for both individual intervention and multifaceted approach, 0 for control. The multifaceted bundle and feedback variable equaled 1 for bundle and 0 otherwise.
Poisson regression with robust variance estimation was then used to estimate the incremental risk ratios for multifaceted approach, follow-up for ≥60-days, and treatment. Poisson regression with robust variance estimation was used because it provides unbiased estimation of incremental risk ratios (e.g., in comparison with logistic regression that estimates odds ratios) [14]. (Risk ratios are needed for use of our results by organizations’ individual economic analyses.) Half of the patients (2414/4865) were controls, 0 for both variables (Table 1). We treated P <.025 as statistically significant and used 97.5% confidence intervals because we had two comparisons of interest, bundle versus individual and duration of follow-up. (The treatment variable is a dummy, wherein pooling the studies cannot change or provide insight into the two older trials with single interventions that both failed to detect efficacy [7,8].) Calculations were performed using Stata 17.0 (StataCorp, College Station, TX). Tests of validity checked rationales for pooling groups. Sensitivity analysis excluded covariates.
Table 1:
Baseline Demographics for Control Patients Stratified by the Occurrence of Surgical Site Infectiona
| Variable | SSI Yes | SSI No | P-Valuea |
|---|---|---|---|
| Follow-up period | |||
| Overall, follow-up for 30 to 90 days, % (N) | 4% (96) | 96% (2318) | |
| Overall, follow-up ≥60 days, % (N) | 8% (39) | 92% (449) | |
| American Society of Anesthesiologists Physical Status | |||
| ASA 1 or 2, % (N) | 2% (31) | 98% (1229) | <0.001 |
| ASA > 2, % (N) | 6% (65) | 94% (1089) | |
| Admitted before day of surgery | |||
| Inpatient preoperatively no, % (N) | 3% (64) | 97% (1826) | 0.007 |
| Inpatient preoperatively yes, % (N) | 6% (32) | 94% (487) | |
| Case duration | |||
| Surgical case duration ≤ 2 hours, % (N) | 3% (44) | 97% (1303) | 0.047 |
| Surgical case duration > 2 hours, % (N) | 5% (52) | 95% (1015) | |
| Patient sex | |||
| Patient sex male, % (N) | 5% (53) | 95% (1081) | 0.12 |
| Patient sex female, % (N) | 3% (43) | 97% (1237) | |
| Surgical specialty | |||
| General abdominal surgery, % (N) | 2% (7) | 98% (301) | 0.12 |
| Not general abdominal surgery, % (N) | 4% (89) | 96% (2017) | |
| Orthopedic surgery, % (N) | 3% (17) | 97% (550) | 0.22 |
| Not orthopedic surgery, % (N) | 4% (79) | 96% (1767) | |
| Patient age | |||
| Years, Mean ± standard deviation (N) | 59 ± 14 (96) | 57 ± 17 (2318) | 0.25 |
| Wound | |||
| Dirty wound, % (N) | 5% (10) | 95% (182) | 0.34 |
| Not dirty wound, % (N) | 4% (86) | 96% (2135) | |
SSI Surgical site infection
Sample sizes among the tests are functionally all the same, 2413 (e.g., dirty wound) or 2414 (e.g., patient age). Therefore, each test result provides information about the relative (univariate) importance of the variables. General abdominal surgery and orthopedic surgery are each treated as binary variables to make this feasible.
Absolute expected reductions in infections and thus estimated net cost (savings) were estimated by performing logistic regression and then calculating marginal means. Logistic regression was used so that marginal means would be calculated for probabilities, not counts as for Poisson regression. The statistical model was otherwise the same. Robust variance estimation was used.
3. Results
A total of 4,860 patients had complete data and were included for the primary analysis. Baseline patient demographics stratified by development of surgical site infections are shown in Table 1 for the control groups. The observed incidence of surgical site infection was 8.0% among control patients with electronic chart review of all encounters for ≥60 days postoperatively (Table 2). Using the four control groups, the unadjusted estimate for relative risk of detecting surgical site infection with follow-up for at least 60-days was 2.70 relative to 30 days (Table 2). Three variables with calculated P <0.10 were included in the multivariable model: ASA, inpatient preoperatively, and duration (Tables 1 and 2). There was no residual effect of study group on estimated incidences of infection (P =0.36) (Tables 3 and 4).
Table 2.
Incidences of Surgical Site Infection among Combinations of Follow-up Period, Multifaceted Bundle and Feedback, Treatment Group, and Demographic Variablesa
| SSI % (N) | |
|---|---|
| Follow-up ≥60 days, control group | 8.0% (39/488)b |
| Follow-up ≥60 days, multifaceted program and feedback | 2.7% (15/549) |
| Follow-up 30 days, no multifaceted program and feedback | 2.9% (112/3828) |
| Follow-up 30 days, control group | 3.0% (57/1926)b |
| Follow-up 30 days, treatment group, one of the single interventions | 2.9% (55/1902) |
| Follow-up 30 days, ASA 1–2 | 2.0% (41/2010) |
| Follow-up 30 days, ASA 3–5 | 3.9% (71/1818) |
| Follow-up ≥60 days, ASA 1–2 | 2.9% (17/582) |
| Follow-up ≥60 days, ASA 3–5 | 8.1% (37/455) |
| Follow-up 30 days, Surgical Duration ≤ 2 hours | 2.2% (49/2263) |
| Follow-up 30 days, Duration > 2 hours | 4.0% (63/1565) |
| Follow-up ≥60 days, Duration ≤ 2 hours | 6.4% (22/341) |
| Follow-up ≥60 days, Duration > 2 hours | 4.6% (32/696) |
| Follow-up 30 days, Outpatient preoperatively, elective surgery | 2.9% (93/3217) |
| Follow-up 30 days, Inpatient preoperatively or urgent surgery | 3.1% (19/611) |
| Follow-up >60 days, Outpatient preoperatively, elective surgery | 4.1% (20/493) |
| Follow-up >60 days, Inpatient preoperatively or urgent surgery | 6.3% (34/539) |
SSI Surgical site infection
ASA American Society of Anesthesiologists (ASA) Health Classification Status
Table 1 is limited to the control groups, while this table includes all patients shown in various categories.
The ratios of control groups (39/488)/(57/1926) = 2.70, an unadjusted risk ratio for the effect of the follow-up period on detected surgical site infections.
Table 3.
Multivariable Model Predicting Surgical Site Infection, N = 4860 patients
| Incremental risk ratio | P-value | 97.5% confidence interval | |
|---|---|---|---|
| Follow-up for 60–90 days versus 30 daysa | 2.61 | <0.001 | 1.62 to 4.21 |
| Multifaceted (bundle and feedback) (1) versus not (0)b | 0.32d | 0.001 | 0.15 to 0.70 |
| Treatment (1) versus none (i.e., control) (0)c | 1.00 | 0.98 | 0.66 to 1.51 |
| American Society of Anesthesiologists’ physical status >2 versus 1 or 2 | 2.10 | <0.001 | 1.46 to 3.01 |
| Duration > 2 hours versus ≤ 2 hours | 1.32e | 0.10 | 0.91 to 1.91 |
| Inpatient preoperatively or urgent surgery versus outpatient preoperatively (scheduled) | 1.11e | 0.51 | 0.77 to 1.60 |
For design, a univariate analysis was performed limited to patients in the control groups. There was no significant difference in detected surgical site infections with 60-day follow-up (randomized trial) and 90-day follow-up (observational study), incremental risk ratio 1.05, P = 0.89.
For design, a univariate analysis was performed limited to patients in the treatment groups of the randomized trial and observational studies with bundle and feedback. There was no significant difference in incidences of surgical site infections, randomized trial relative risk 0.30, P = 0.24. The 95% confidence interval was wide, 0.040 to 2.49, because there were few infections in these treatment groups.
For design, a univariate analysis was performed limited to patients in the treatment groups of the two studies with single interventions, hand hygiene or vascular care. There was no significant difference in incidences of surgical site infections hand hygiene versus vascular care relative risk 0.73, P = 0.36.
Among all control patients (Treatment = 0), the observed incidence of surgical site infections was 4.0% (Table 1 first row, because that table includes only control patients). With Treatment = 1, the predicted mean absolute risk reduction with multifaceted bundle (1) versus not (0) equals 2.8% (Table 4). The (4.0%−2.8%)/4.0% = 0.30 is close to the estimated relative risk of 0.32. Repeating using control patients with follow-up for at least 60 days, the observed incidence of surgical site infection was 8.0% (Table 1). With Treatment = 1, the predicted mean absolute risk reduction with multifaceted bundle (1) versus not (0) was 5.3% (Table 4). Again, appropriately, the (8.0%−5.3%)/8.0% = 0.34, close to the estimated relative risk of 0.32.
Table 4.
Multivariable Logistic Regression Model for Surgical Site Infection, N = 4860 patients
| Odds ratio | P-value | 97.5% confidence interval | |
|---|---|---|---|
| Follow-up for 60–90 days versus 30 daysa | 2.77 | <0.001 | 1.66 to 4.63 |
| Multifaceted (bundle and feedback) (1) versus not (0)b | 0.30d | 0.001 | 0.13 to 0.68 |
| Treatment (1) versus none (i.e., control) (0)c | 1.00 | 0.98 | 0.65 to 1.53 |
| American Society of Anesthesiologists’ physical status >2 versus 1 or 2 | 2.18e | <0.001 | 1.49 to 3.16 |
| Duration > 2 hours versus ≤ 2 hours | 1.33e | 0.10 | 0.90 to 1.96 |
| Inpatient preoperatively or urgent surgery versus outpatient preoperatively (scheduled) | 1.12e | 0.67 | 0.76 to 1.64 |
For design, a univariate analysis was performed limited to patients in the control groups. There was no significant difference in detected surgical site infections with 60-day follow-up (randomized trial) and 90-day follow-up (observational study), odds ratio 1.06, P = 0.89.
For design, a univariate analysis was performed limited to patients in the treatment groups of the randomized trial and observational studies with bundle and feedback. There was no significant difference in incidences of surgical site infections, randomized trial odds ratio 0.30, P = 0.24. The 95% confidence interval was wide, 0.040 to 2.25, because there were few infections in these treatment groups.
For design, a univariate analysis was performed limited to patients in the treatment groups of the two studies with single interventions, hand hygiene or vascular care. There was no significant difference in incidences of surgical site infections hand hygiene versus vascular care odds ratio 0.72, P = 0.36.
For postestimation of marginal means, physical status, duration, and inpatient preoperatively were kept at observed values. Among all control patients (Treatment = 0), the observed incidence of surgical site infections was 4.0% (Table 1 first row, because that table includes only control patients). With Treatment = 1, the predicted mean absolute risk reduction with multifaceted bundle (1) versus not (0) (i.e., versus single intervention because Treatment = 1) was 2.8% (97.5% confidence interval 1.1% to 4.6%, P < 0.001). These calculations were then repeated using a subset of the control patients (Treatment = 0), those with follow-up for at least 60 days. They had an observed incidence of surgical site infection was 8.0% (Table 1). With Treatment = 1, the predicted mean absolute risk reduction with multifaceted bundle (1) versus not (0) (i.e., single intervention because Treatment = 1) was 5.3% (97.5% confidence interval 1.0% to 9.6%, P = 0.006).
A multifaceted approach was associated with an estimated 68% reduction in postoperative surgical site infections (risk ratio 0.32, 97.5% CI 0.15–0.70, P=0.001) as compared to single interventions (Table 3). This estimate of relative efficacy of multifaceted vs. single intervention anesthesia work area preventive approaches is important for quantifying the expected net cost (saving) from preventing surgical site infections. There were approximately 2.61-fold more surgical site infections detected with follow-up for at least 60 days (97.5% CI 1.62 to 4.21, P <0.001) relative to 30 days (Table 3). This result shows the importance of the duration of patient follow-up when monitoring surgical site infections.
Sensitivity analyses were performed showing validity of the model results and lack of substantive influence of the covariates on our two primary estimates (Table 3). Excluding covariates, the risk ratio for multifaceted (bundle and feedback) was 0.35 (97.5% CI 0.16–0.77, P =0.003) and for follow-up 60–90 days was 2.70 (97.5% CI 1.72–4.24, P <0.001).
The predicted mean absolute risk reduction with multifaceted bundle versus single intervention was 5.3% (97.5% confidence interval 1.0% to 9.6%, P = 0.006). Repeating using all control patients, the incidence of surgical site infection would have been 4.0% among control patients. The predicted mean absolute risk reduction with multifaceted bundle versus single intervention was 2.8% (97.5% confidence interval 1.1% to 4.6%, P < 0.001).
4. Discussion
Effective implementation of anesthesia work area infection control measures can prevent surgical site infections before they develop and decrease the need for antibiotic use [7,8,9,10]. In the current study, we assessed the relative efficacy of multifaceted vs. single intervention approaches to anesthesia work area infection control, and we characterized the importance of duration of follow-up for surgical site infection development. We learned that a multifaceted approach with feedback is more efficacious for prevention of surgical site infections than single interventions and that a follow-up period of at least 60 days is needed for accurate detection of surgical site infections. In addition, a best practice for anesthesia work area infection control involves implementation of an evidence-based, multifaceted approach (i.e., bundle of interventions optimized by feedback) and at least a 60-day follow-up period for detection of surgical site infections. Lack of sensitivity of results to covariates (e.g., duration of surgery) supports generalizability of the findings.
We previously estimated the net cost benefit of the multifaceted intervention including feedback using S. aureus transmission [15]. Direct cost savings were neutral for an incidence risk ratio of 0.91 and 10% incidence of surgical site infections [15]. In other words, the multifaceted intervention with feedback is net cost savings for absolute risk reductions exceeding 0.91%. The current study’s 97.5% lower confidence limits for the absolute risk reductions were 1.1% based on all control patients and 1.0% among the subset with follow-up for at least 60 days (Table 3). Therefore, when using many inpatient specialties, no net cost can reliably be expected. If, in addition, there were monitoring surgical site infections by specialty and operating room combination and matching of the intervention with those patients most likely to benefit, substantial net cost benefit can be expected [15].
Our work confirmed the significant role of the patient skin site, anesthesia environmental surfaces and equipment, anesthesia practitioners’ hands, and the intravascular devices they manage in intraoperative bacterial transmission [1]. While an evidence-based, multifaceted approach optimized by feedback has been proven efficacious, effective, feasible, cost-effective [9,10,15,16], and practical [17], those comparisons have been to controls, not to single interventions. This has been an important knowledge gap given consumption of resources. We measured the resources used [16,18] but lacked characterization of the relative efficacy of a multifaceted vs. single intervention approach to anesthesia work area infection control. The data show that a multifaceted approach optimized by feedback is superior to single interventions. These results are consistent with the body of literature demonstrating that single interventions are prone to failure [19,20]. They also are the information needed for the sites aiming to implement multifaceted care but needing estimates of cost versus net cost savings for implementation relative to their multiple, departmentally heterogeneous, single intervention initiatives.
A strength of our study is that the studies of single intervention comparators measured and confirmed the fidelity of those interventions [7,8]. Personalized body worn hand-hygiene devices increased hourly hand decontamination events several-fold compared with conventional wall-mounted devices [7]. Catheter hub disinfection significantly reduced the incidence of primary stopcock lumen contamination compared with standard caps [8].
We also examined the importance of duration of follow-up for development of surgical site infections, findings that cannot be understated. Before our study it was known that among patients undergoing primary total knee arthroplasty, fewer than half (45%) of the surgical site infections were diagnosed within 30 days [21]. Systematic review had identified duration of follow-up as one key factor for differences in reported incidences of surgical site infections among hospitals [22]. What our results add is that the incidence risk ratio for follow-up is as large an effect quantitatively as the infection control approach. Functionally how the modeling determined this was by comparing control groups (Table 3). The two studies having longer periods of follow-up had more infections detected. If a hospital chooses to follow patients and provide feedback for one month, there will be both a false assurance of adequate infection control measures, by missing infections, and lost opportunity to maximize patient benefit and realize cost savings. These results clearly show that it is in the best interest of both the hospital and the patient to follow patient data for at least 60 postoperative days. However, the lower 97.5% confidence limit of 1.62 is large for the relative effect expected by comparing other randomized trials based on duration of follow-up (e.g., 6.7% with 30-day follow-up in Germany [23] versus 8.6% with 180-day follow-up in Australia [24]). We expect that our result for ≥60-day follow-up refers little to the time for infection to develop, rather principally the time in routine US care for medical records (e.g., clinic notes) to contain information about the surgical site infections. Therefore, this finding of follow-up period may be indicative of the four included studies having been performed in the US. Generalizability may depend on the healthcare system and interoperability among organizations’ electronic health record systems.
Additional study limitations include the retrospective design, inclusion of only four trials, and potentially site-specific bacterial strain characteristics. With patient level assessment for nearly 5,000 patients who had been rigorously followed for infection development using the same methodology, and the ability to model covariates, our retrospective analysis was a robust approach to address the primary aims. We included all four existing randomized trials of infection control measures to address intraoperative bacterial transmission arising from anesthesia work area reservoirs including provider hands, the anesthesia machine, and patient skin sites (nares, axilla, and groin) measured before and after care along with the stopcock measured at case end [7,8,9,10]. In addition, we required complete study data of significant covariates, including American Society of Anesthesiologists’ physical status, case duration including surgical and anesthesia time, and preoperative location. Despite this limitation, our findings were entirely consistent with studies outside of the anesthesia work area that demonstrated failure when implemented as single interventions: hand hygiene [19], patient decolonization [20], and environmental cleaning [25]. An important consideration is that while substantial, the impact of the multifaceted approach was limited because the studies [9,10] were our first application and therefore without benefit from current knowledge regarding refined monitoring sample sizes [26], sampling that can be done reliably by a wide variety of individuals [16], such as anesthesia technologists, and the importance of matching sampling with high risk operating room/specialty combinations [15,27]. This knowledge, all obtained during the period of the final (most recent) of the four studies [10], should enhance future applications of the multifaceted approach, including helping to refine the economics. Finally, our results do not mean that single interventions have no efficacy, although that seems likely from P=0.98, because the 97.5% confidence interval was 0.66 to 1.51 (Table 3). Increasing sample sizes beyond 3828 patients (Table 2) could potentially show some (very) small effect.
In conclusion, a multifaceted approach optimized by surveillance feedback and a 60-day follow-up period for development of surgical site infections represent a best practice for intraoperative infection control.
Randomized trial showed that a bundle and feedback reduce surgical site infections
Prospective observational study showed effectiveness of this multifaceted intervention
Comparisons compared with control do not match baseline of many specialties and hospitals
Surgical site infections with multifaceted approach, risk ratio 0.32 vs. single interventions
Many (2.61-fold) more infections detected with follow-up for at least 60 days of medical records
Acknowledgements:
We acknowledge the many contributors to the included four studies. An abstract presenting this work is being presented October 23, 2022, at the American Society of Anesthesiologists meeting in New Orleans.
Funding:
NIH Application 1 R01 AI155752-01A1 entitled The BASIC trial: Improving implementation of evidence-based approaches and surveillance to prevent bacterial transmission and infection.
Declaration of Interests:
Dr. Dexter is Director of the Division of Management Consulting of the University of Iowa Department of Anesthesia, which provides consultations to hospitals, individuals, and corporations, including 3M Healthcare and RDB Bioinformatics. He receives no funds personally other than his salary and allowable expense reimbursements from the University of Iowa. His family and he have no financial holdings in any company related to his work. A list of all the Division’s consults is available in his posted curriculum vitae at FranklinDexter.net/Contact_Info.htm. Drs. Brown and Wall are without disclosures. Dr. Loftus received research funding from Sage Medical Inc., BBraun, Draeger, Surfacide and Kenall, has one or more patents pending, and is a partner of RDB Bioinformatics, LLC, and 1055 N 115th St #301 (Omaha, NE, USA) a company that owns OR PathTrac, and has spoken at educational meetings sponsored by Kenall (AORN) and BBraun (APIC).
Footnotes
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