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