Geisinger Medical Center (online-audio-converter.com)

The discussion focuses on the impact of smoking on post-surgical site infections in total joint replacement patients. Research findings indicate smoking increases infection risk, but other modifiable factors like BMI and uncontrolled diabetes play significant roles too. Studies show smokers have higher odds of developing infections, leading to costly hospital stays and emotional distress for patients and nurses. Emphasizes the need for pre-surgical optimization to address various risk factors beyond smoking. Collaboration between researchers highlighted diverse perspectives and insights on managing infection risks in joint replacement surgeries. In the surgical patient, how does smoking compared to non-smoking affect the post-surgical site infections and undergoing a total joint replacement? So I'm Keith D'Amato and I'm Carissa Dombrowski and we're just going to talk a little bit about surgical site infections and how smoking can increase the risk of infection. So I work in the PACU setting, so in my PACU setting I see a lot of reoccurring surgeries for the joint replacement. Patients are coming in for some revisions due to infection. A lot of them come in needing washouts and another revision of the joint afterwards. Do you think you see a lot more incident of smoking when that happens, when they're being readmitted or those kinds of things? Yeah, so a lot of them are smokers, they do kind of a screening process with the initial joint replacement, but it's not really followed through the pre-operative phase, so as patients are getting worked up for surgery, they go through these questionnaires, they do screen them for nicotine use, but there's no education or no protocol to get them through with surgery. So patients continue to smoke all the way up through their surgery and after their surgery. Okay, and this is something that we decided to use because we are very inclined to advocate to stop smoking, so we wanted to talk a little bit about our research and how we started it. I started with a health science librarian at Geisinger and we ended up going through some databases. She told me that they don't like to use EBSCO hosts due to the searches tend to search like relevance instead of the selective, so the results were very, they can be very high and we could get into a ton of thousands of results. So looking at surgical site infections, we typed that in, we included total joint replacement and then we used and and included smoking. Smoking was such a broad term that it ended up coming up with thousands of results. I agree. You could find a lot of different studies on smoking. Yeah, and smoking is defined differently, so we wanted to make sure that it was tobacco use, cigarette and possibly vape and that's about it. So we ended up trying smoking cessation in the search and that yielded only 13 and then of those 13, we ended up choosing two. Both of my articles were quantitative. How about you? I had a lot of difficulty finding good literature to go in and review, but I think the searches that I was able to get were mostly quantitative. It wasn't until later on that I found a good qualitative study that really showed the bigger picture of joint replacements and how impactful it was on both the patient and the nurses. Yeah, and interesting just to follow up with Kate's search, it was funny because once we went through all of our articles and we were putting everything together, we had realized that the searches that I had come up with through the databases were very specific to just total joint replacement, surgical infection and smoking versus the non-smoking patient, which was interesting because then when you go on and you Google search, as such as you did, your searches became something more broader. We were finding out that there maybe were more other modifiable risks that were at a higher risk of causing surgical site infections rather than just smoking. That was just something interesting that I wanted to point out because in my search and in my articles that I had found, the results really do point to smoking does yield a higher incident rate for surgical site infections. It's interesting because if you're searching for that, you're going to find it. That's something that I wanted to bring up through the podcast, like if anybody else realized that whatever you're going to search, you're going to find. You're going to yield that, whereas her broader search from Google found that BMI and diabetes and other modifiable risks actually cause higher rates of surgical site infections. What was it? Comorbidities? Comorbidities, uncontrolled glucose levels prior to surgery, just pretty much any medication. If they were on immunosuppressants or hormone replacements, a lot of those also really affected the surgical site infections after a joint replacement. I just wanted to talk a little bit about some of the findings that I did find. One of my articles, the researchers had done a previous large study of 33,000 veterans who underwent a total hip or a total knee arthroplasty. They showed that current smokers had an adjusted odds ratio of 1.4 for 30 days of SSIs compared to never smokers. That's a significant study right there. They also said that in the current study then that they found in the smaller cohort, it was current tobacco users were at 2.3 times higher odds of developing post-surgical deep infections compared to current non-smokers. Those deep infections, they're right down to the hardware that they put in for that joint replacement. That's pretty significant. Then we're looking at possible amputation if it doesn't clear up. Then we're looking at the hospital cost. Do you want to touch a little bit on that? For the hospital, in the one qualitative study that I pulled up for my research, it really gave a good insight on what patients and the nursing staff face. Just some feedback in this study. It was 20 nurses who gave their input in an interview of what they feel. The one was very shocking, but it makes sense. This is the comment that they said. They would need much more support in coping with the infection, less from the nursing side as it's not simply our job. We already talked to them, but they need much more professional support from a psychosomatic or a psychological, similar to the oncology patients. These patients still somehow are not focused, and nobody is aware that they also have a psychological trauma that has resulted from this deep tissue infection that's right down to their joint. Just, again, about the hospital phase. You're having higher increase in cost because they're stuck with this infection. They're probably having a lot of antibiotics given. I tend to see that when people come in on my MedSearch unit for INDs and washouts, weeks after a procedure, they're then there for another six weeks or longer, unless they can get a pick and go home with it. We're seeing that this is overall emotionally damaging to the patient because as they're there in the hospital, if they're in an isolation room, like you had mentioned once before, then there goes that. Do you want to touch briefly on the mental side of that? Oh, yes. Another feedback from another nurse in the study, she said that they wished that they had more time available to spend with these patients who are then stuck in an isolation room, but they simply don't have the amount of time to sit with them. Family members also don't have the time off work to consistently come in and sit with these patients. So you start to see a lot of what they see in the ICU, so a lot of delirium, emotional depression. Oh, yes, we see that a lot in the hospital itself. Being a patient is really tough. So then something else I also want to circle back on, Carissa, also in this other study that I had read, it also affects the patient's quality of life. So let's say they do their antibiotics and they have to go in for multiple surgeries. So they can do numerous washouts. They can do a two-step re-implant for another joint. These patients are then facing extensive recovery time, which also impacts the hospital cost. So the one study I read said that there was, I think it was like a $500,000 increase in hospital expenses related to the revision. That's a lot when you're talking about from a cost perspective in the hospital. They take that very seriously. And then kind of roping it back into the smoking versus non-smoking, so we were able to find a lot of sources that state that overall we were able to summarize in our literature review that smoking is not the only catch-all when you're looking at joint replacements. So I think the one study that really opened our eyes, they took everything into consideration. So they really grouped everything down to a risk factor and put all the patients in a group. They even did a hip joint versus knee joint replacement, and they just funneled down through the infection. And we actually found out that smoking was not the greatest risk factor and that we should really be looking at these patients a little bit more closely in the pre-surgical optimization period. I know from my experiences, we see patients on day of surgery coming in for a joint replacement with a blood sugar that is uncontrolled. So when I say uncontrolled, it's greater than 170. By senior standards, they like the glucose to be below 170 prior to surgery. So what we're often having to do as a pre-surgical nurse is we're giving insulin, we're doing an insulin drip. But that might not be enough for these joint replacement patients. Mm-hmm. Yeah. And just to, you know, again, to say, like, it depends on your research. I use databases, and I would have never expected that there was other modifiable risks that were more high risk than smoking because my research showed that smoking was such a high risk. And then to, like, look outside the box and be like, wow. You know, there's other research out there that shows that smoking, yeah, it's not great, but there's actually worse things like BMI and the diabetes uncontrolled. So it was interesting to see, you know, having two different people look at two different ways of researching it. Yeah. And what you really got out of it. And I really did like to sit down at the end of all this because Carissa and I, we worked very closely throughout this whole process, and I feel we were able to bring those separate ideas back and forth with each other, things that she may not have found that I found and vice versa because she found a lot of information that I didn't find. Mm-hmm. So it was very nice to come together as a group and put this project together. And like our last qualitative article that you kind of just touched on too, like the emotional aspect, I do want to point that out just at the end of the podcast here. If anybody else is interested in this surgical site infection, take a look at that. That really brought the nurse's perspective into it, the nurse's emotional well-being. That was a really great article. What was the title of that article? The article was Managing a Periprosthetic Joint Infection, a Qualitative Analysis of Nursing Staff Experience. And we can go ahead and link that in as well. That way, if anybody is interested, they can review it. I also just want to point out one more thing with our study before we wrap this up. With Carissa's data that she was able to pull versus mine, some of her information was a little farther back in time than I was. Yeah, yeah. But it was still relevant because nobody did further studies on those. Yeah, something that was just smoking versus non-smoking on the total joint hasn't been researched in at least, I guess, ten years, unfortunately. So that's why we had to kind of go out the broader spectrum here for our research. That's pretty much what we did, and thanks for listening. I hope you enjoyed this topic. All right, guys. Thank you. Bye.