Translation and validation of the Greek version of the “ASEPSIS” scoring method for orthopaedic wound infections

https://doi.org/10.1016/j.ijotn.2018.11.006Get rights and content

Abstract

Introduction

The ASEPSIS scoring method represents an important instrument for assessing surgical wounds for infections. The purpose of this study was to translate and validate the ASEPSIS in Greek.

Methods

The ASEPSIS was translated from English to Greek, back-translated to English, and reviewed by an expert committee. Reliability and validity analyses were performed in a sample of 111 consecutive orthopaedic patients. Patients were assessed during hospitalisation (using the ASEPSIS) and at three months after discharge (by phone, through questions about wound healing).

Results

Face validity was considered to be very good. The surgical wound infection rate was 6.3% with the Centers for Disease Control and Prevention criteria and 3.6% with the ASEPSIS (i.e. score ≥21) (p < 0.001). At three months, 7.4% of the participants reported they were given antibiotics for wound infection and 5.4% needed a rehospitalisation. The ASEPSIS score was correlated to the therapeutic administration of antibiotics (p = 0.001) and the need for rehospitalisation (p < 0.001) during the follow-up. The inter-rater agreement was 90%.

Conclusions

The Greek version of the ASEPSIS can be used by both surgeons and nurses. However, it should be used with caution until more studies are conducted with larger samples and in patients with different surgical procedures.

Introduction

Surgical wound infections are difficult to define, because of their wide range of possible features. There are several definitions, the most popular being the definition of the Centers for Disease Control and Prevention (CDC), the United Kingdom Nosocomial Infection National Surveillance Scheme (NINSS) and the ASEPSIS scoring method (Ashby et al., 2010; Bruce et al., 2001), while there is no validated universal system for their assessment (Petrica et al., 2009).

The most widely recognised definition of infection is the CDC criteria (Petrica et al., 2009), where surgical wound infections are classified into superficial incisional (where only the skin/subcutaneous tissue are involved), deep incisional (where fascial and muscle layers are involved) and organ/space infections (i.e. affecting any space other than the incision, which was manipulated during the operation) (CDC, 2017). However, CDC criteria also include “diagnosis by physician”, which can be subjective. Alternatively, the ASEPSIS is an objective scoring system based on the presence of clinical findings (Hedrick et al., 2015).

The ASEPSIS is a quantitative method that provides a score related to the severity of infection using objective criteria based on wound appearance and the clinical consequences of the infection (Petrica et al., 2009). ASEPSIS is an acronym for: Additional treatment; Serous discharge; Erythema; Purulent exudate; Separation of deep tissues; Isolation of bacteria; and Stay as inpatient for a prolonged period (over fourteen days). Although it was first used in wounds after cardiothoracic surgery, it has been widely used in different surgical settings and patients (Bruce et al., 2001), including patients undergoing orthopaedic surgeries (Chiew and Theis, 2007; Romanò et al., 2016). Furthermore, the ASEPSIS has good reliability (Bruce et al., 2001; Wilson et al., 1986a) and it is simple to use; therefore we believe it is the most suitable instrument to use in Greece on a regular basis.

Section snippets

Background

Surgical wound infections are among the most common healthcare-associated infections and are associated with longer hospital stays, additional surgical procedures, treatment in intensive care units, and higher mortality (European Centre for Disease Prevention and Control, 2018).

Surgical wound infections may occur up to thirty days after a surgery or up to one year after a surgery in which implants are used (Owens and Stoessel, 2008). Every surgical wound is colonized by bacteria, but infection

Description of the ASEPSIS

A score in the ASEPSIS between “0” to “10” corresponds to satisfactory healing, while scores between “11” to “20” indicate a disturbance of healing, scores between “21” to “30” correspond to minor infection, scores between “31” to “40” correspond to moderate infection and, finally, scores higher than “41” correspond to severe infection (Wilson et al., 2006).

Ideally, 5 daily scores must be obtained (e.g., for 5 out of the first 7 postoperative days) and all ASEPSIS scores from the patient's

Descriptive results

In total, 111 patients participated in the study (i.e. 111 orthopaedic surgical wounds) during their hospitalisation and 68 (61.3%) at three months. All of the patients who were contacted agreed to participate in the second part of the study (response rate = 100%). The rest of the patients could not be contacted (e.g., change of telephone number, not answering the phone after 3 attempts), while 3 patients (2.7%) died during the follow-up period (one due to multiple organ dysfunction syndrome,

Discussion

There are several definitions for surgical wound infections, the most popular being the definition of the CDC; however, these definitions include subjective measures for wound assessment. The validity and reliability of studies of wound infections are significantly determined by the appropriateness of the instruments used. Therefore, the instruments should be characterized by increased validity and reliability. However, an instrument with high validity and reliability in a specific population

Conclusions

Validity and reliability of the Greek version of the ASEPSIS were satisfactory in the present study. Overall, the ASEPSIS is an objective, brief and simple instrument, for use by both surgeons and nurses. We believe it is the most suitable method for the assessment of surgical wounds in Greece, not only in the present study, but also on a regular basis and in research. However, before it could be used on a larger scale, more studies should be conducted in patients having different surgeries.

Author contributions

PC, VAK, TBG and PW were responsible for the study conception and design. PC and VAK performed the data collection and PC was responsible for the drafting of the manuscript. Translation of the instrument and obtaining permission from the original authors and ethical permissions for the data collection in the hospital was performed by PC and VAK. Cultural adaptation was made by TBG. PC and PG performed the data analysis. All authors have made their critical revisions and approved the final

Ethics in publishing

The study was approved by the hospital's Institutional Review Board (11193/17-09-2014, date of approval 31-10-2014). The principles of the Declaration of Helsinki were applied throughout the study. An informed consent was obtained from all participants. All patient data were coded and only the researchers had access to them.

Conflicts of interest

No conflict of interest is declared by the authors.

Role of the funding source

No funding was received for this study.

References (72)

  • B.H. Kapadia et al.

    The economic impact of periprosthetic infections after total hip arthroplasty at a specialized tertiary-care center

    J. Arthroplasty

    (2016)
  • S.M. Kurtz et al.

    Infection burden for hip and knee arthroplasty in the United States

    J. Arthroplasty

    (2008)
  • W.J. Metsemakers et al.

    Infection after fracture fixation of the tibia: analysis of healthcare utilization and related costs

    Injury

    (2017)
  • J.P. Ouanes et al.

    Special anesthetic consideration for the patient with a fragility fracture

    Clin. Geriatr. Med.

    (2014)
  • C.D. Owens et al.

    Surgical site infections: epidemiology, microbiology and prevention

    J. Hosp. Infect.

    (2008)
  • E.M. Padegimas et al.

    Periprosthetic shoulder infection in the United States: incidence and economic burden

    J. Shoulder Elbow Surg.

    (2015)
  • L.A. Poultsides et al.

    In-hospital surgical site infections after primary hip and knee arthroplasty--incidence and risk factors

    J. Arthroplasty

    (2013)
  • E. Rennert-May et al.

    Validity of administrative data in identifying complex surgical site infections from a population-based cohort after primary hip and knee arthroplasty in Alberta, Canada

    Am. J. Infect. Contr.

    (2018)
  • M. Roumbelaki et al.

    Surveillance of surgical site infections at a tertiary care hospital in Greece: incidence, risk factors, microbiology, and impact

    Am. J. Infect. Contr.

    (2008)
  • A.P. Wilson et al.

    Comparison of wound scoring methods for use in audit

    J. Hosp. Infect.

    (1998)
  • E. Ashby et al.

    How will surgical site infection be measured to ensure “high quality care for all”?

    J. Bone Joint Surg. Br. Vol.

    (2010)
  • D.E. Beaton et al.

    Guidelines for the process of cross-cultural adaptation of self-report measures

    Spine

    (2000)
  • Centers for Disease Control and Prevention

    Procedure-associated module- surgical site infections

  • Centers for Disease Control and Prevention

    National healthcare safety network reports

  • P. Cherubino et al.

    Revision in cemented and cementless infected hip arthroplasty

    Open Orthop. J.

    (2013)
  • Y.F. Chiew et al.

    Comparison of infection rate using different methods of assessment for surveillance of total hip replacement surgical site infections

    ANZ J. Surg.

    (2007)
  • P. Copanitsanou et al.

    Posttraumatic stress, depressive emotions, and satisfaction with life after a road traffic accident

    Orthop. Nurs.

    (2018)
  • P. Copanitsanou et al.

    Empowering education of arthroplasty patients' significant others in three Southern European countries

    Int. J. Older People Nurs.

    (2018)
  • J. Cross

    Nursing the patient with altered cognitive function

  • S. Ding et al.

    Surgical wound assessment and documentation of nurses: an integrative review

    J. Wound Care

    (2016)
  • L.B. Engesaeter et al.

    Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0–14 years in the Norwegian Arthroplasty Register

    Acta Orthop. Scand.

    (2003)
  • European Centre for Disease Prevention and Control

    Surveillance Systems Overview [internet]

    (2017)
  • European Centre for Disease Prevention and Control

    Surgical site infections

  • European Commission

    Health care & long-term care systems: Greece. An excerpt from the joint report on health care and long-term care systems & fiscal sustainability (institutional paper)

  • P. Galanis

    Validity and reliability of questionnaires in epidemiological studies

    Arch. Hellenic Med.

    (2013)
  • A. Gikas et al.

    Hellenic infection control network

    Infect. Control Hosp. Epidemiol.

    (2004)
  • Cited by (0)

    View full text