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Incidence and Impact of Reported Infectious Endophthalmitis Events Following Cataract Surgery in Pennsylvania Ambulatory Surgery Centers

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Incidence and Impact of Reported Infectious Endophthalmitis Events Following Cataract Surgery in Pennsylvania Ambulatory Surgery Centers Incidence and Impact of Reported Infectious Endophthalmitis Events Following Cataract Surgery in Pennsylvania Ambulatory Surgery Centers By Lynette Hathaway, MSN, RN, Shawn Kepner, MS & Rebecca Jones, MBA, RN DOI: 10.33940/infection/2019.12.3 Corresponding author Patient Safety Authority Disclosure: The authors declare that they have no relevant or material financial interests. 24 I PatientSafetyJ.com I December 2019 Patient Safety I December 2019 I 25 Abstract eye begin to break down and cause clouding.10 As the 2018, to identify and analyze reports of infectious syndrome (TASS) with or without identified surgical elderly population in Pennsylvania continues to grow,11 endophthalmitis following cataract surgery (“post- procedures, postoperative complications following a Infectious endophthalmitis is a severe eye infection cataract surgeries are also on the rise.12 Given that cataract endophthalmitis”). Key search terms cataract procedure not identified as endophthalmitis, that can occur following cataract surgery. In this most cataract surgeries are performed in ambulatory included “endophthalmitis,” as well as a combination postponed or cancelled procedures, and other unre- study, we sought to explore post-cataract infectious surgery centers (ASCs) and outpatient departments3 it of the terms “infection” and “eye,” and “infection” lated events (e.g., break in sterile technique, drug re- endophthalmitis events reported by ambulatory sur- is no surprise that more than one million cataract pro- and “cataract.” Our initial search yielded 349 reports call, policy not followed). gery centers (ASCs) in Pennsylvania. We queried the cedures were performed in Pennsylvania ASCs between which the first two authors independently reviewed Pennsylvania Patient Safety Reporting System (PA- 2009 and 2018.12 and analyzed to determine whether they represented Results PSRS) database for post-cataract endophthalmitis cases. We then post-cataract en- Cataract surgery is compared our findings and resolved discrepancies Rate dophthalmitis events endogenous (bloodborne) endophthalmitis noun one of the most com- through joint review and consensus. A subject matter We identified 174 reports of post-cataract endoph- that occurred be- en· dog· e·nous en· doph· thal·mi·tis mon ocular surgical medical expert was also consulted to confirm validity. thalmitis over a 10-year period between 2009 and tween 2009 and 1 “may occur from a number of systemic risk factors that spread procedures in med- bacteria or fungi from the primary source of infection into the 2018. We then obtained current procedure termi- 2018. In the 10 cal- 2,3 13,14 Inclusion Criteria eye.” icine and one of nology (CPT) codes from the Pennsylvania Health endar years analyzed, the most frequent exogeneous endophthalmitis noun Reports meeting the following inclusion criteria were Care Cost Containment Council (PHC4) to calculate we identified 174 surgical procedures ex· og· e·nous en· doph· thal·mi·tis classified as post-cataract endophthalmitis events: the rate of post-cataract endophthalmitis events re- reports of post-cata- performed by oph- 1 “may occur after ocular trauma, following a corneal infection, ported by Pennsylvania ASCs each year during the ract endophthalmitis, or after eye surgery—particularly cataract surgery.”4-7 thalmic surgeons in study period. As seen in Figure 1, rates ranged from with rates per 1000 the United States.15 0.05 to 0.19 per 1000 cataract procedures. In the cataract procedures While cataract surgery 10 calendar years analyzed, we noted what could be ranging from 0.05 in 2009 to 0.19 in 2018. The vast is usually successful and safe,6 it is not without risk. an increase in rates of post-cataract endophthalmitis majority of these events were classified as serious The precipitating procedure was identified as a cataract surgery events, however the increase was not statistically sig- (93%; n = 162 of 174), reflecting harm to patients, Infectious endophthalmitis is a rare yet significant 3,4 nificant (P = 0.2530 > 0.05). with one resulting in enucleation (the need to remove complication of cataract surgery. Defined as an the affected eye). Healthcare staff and all involved infection of the intraocular fluids (aqueous and/or 3 Age/Gender stakeholders should act now by identifying sources vitreous) and cavities, infectious endophthalmitis is AND Patient age was approximately symmetric about the of potential perioperative contamination, adhering to accompanied by complaints of decreased vision, eye mean value of 73 years with a skewness statistic of evidence-based infection prevention practices, and pain, and redness in the operative eye. It typically -0.18 (N = 174). The median and mode were also 73. prioritizing areas of opportunity for improvement. occurs within days of surgery, but may not cause The term symptoms until weeks post-procedure, depending The report reflected endophthalmitis As seen in Figure 2, a very small number of reports a clear diagnosis 1 did not appear were related to patients younger than 50 years of Keywords: infectious endophthalmitis, eye infection, on the causative microorganism. A diagnosis of using the term OR in the report, but age. Of the 174 events identified, females accounted cataract surgery, postoperative endophthalmitis, endophthalmitis following cataract surgery is usually “endophthalmitis” one or more of healthcare-associated infection based on clinical presentation thought to be related the following were for 53.45% of the reports, which is not significantly (n=120) to infection, with cultures of vitreous and/or aqueous present: different than the estimated PA population comprised Introduction fluids.1,5,16 Although the exact manner of development • Event was of 51.06% females (P = 0.5286 > 0.05). for infectious endophthalmitis is unknown, potential Exclusions described as an “infection” Harm Score ndophthalmitis is a serious eye infection that can sources of contamination during cataract surgery Excluded events consist- lead to permanent harm, including blindness.1 include intraocular instruments and the intraoperative ed of unconfirmed diag- • Patient was The vast majority (93%; n = 162 of 174) of post- There are two types of endophthalmitis: endog- suite,17 as well as unsterile solutions/material or the noses of endophthalmitis, treated with cataract endophthalmitis events were reported as an intravitreal 1,18 Serious Events, reflecting harm to patients. Most were Eenous (bloodborne), which may occur from a patient’s eyelid skin flora. Recognizing the lack of diagnoses of endoph- injection of number of systemic risk factors that spread bacteria data surrounding infectious endophthalmitis in the ASC thalmitis or other post- antibiotics reported under harm score “E,” indicating temporary or fungi from the primary source of infection into the setting in Pennsylvania, we sought to identify the rate harm that required treatment or intervention. Based operative infection with • There was 2,3 eye, and exogenous, which may occur after ocular of infectious endophthalmitis events following cataract no surgery identified or evidence of a on the information reported, four of the events trauma, following a corneal infection, or after eye sur- surgery reported by Pennsylvania’s ASCs, explore key not related to a cataract positive culture resulted in permanent harm, one of which required gery—particularly cataract surgery.4-7 Cataracts impact enucleation (the need to remove the affected eye). aspects of the identified cases, and identify strategies to procedure, reported ster- (n=54) the vision of more than 24 million Americans age 40 reduce the risk of this harmful complication. ile endophthalmitis or See Table 1. and older. By age 75, approximately half of all Ameri- toxic anterior segment cans will have visually significant cataracts.8 By the year Methods 2050, the number of people in the United States with cataracts is expected to double from 24.2 million to We queried the Pennsylvania Patient Safety Reporting *PA-PSRS is a secure, web-based system through which Pennsylvania hospitals, ambulatory surgical facilities, abortion facilities, * and birthing centers submit reports of patient safety-–related incidents and serious events in accordance with mandatory 9 System (PA-PSRS) database for events that occurred about 50 million. Aging is the most common cause reporting laws outlined in the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13 of 2002). All reports of cataracts, as the normal proteins in the lens of the between January 1, 2009, and December 31, submitted through PA-PSRS are confidential, and no information about individual facilities or providers is made public. 26 I PatientSafetyJ.com I December 2019 Patient Safety I December 2019 I 27 Figure 1: Rate of Reports of Post-Cataract Endophthalmitis Events by Year Figure 3: Regional Distribution in Reports of Figure 4: Symptoms Identified in Reports of Post-Cataract Endophthalmitis Events (N = 174) Post-Cataract Endophthalmitis Events (n = 82)* 0.2 0.18 0.16 0.14 0.12 0.1 0.08 0.06 0.04 + 0.02 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Rate per 1000 Cataract Procedures *Some reports identified more than one symptom +Other includes tearing, foreign body sensation, headache, photophobia, swelling, purulent drainage, cobwebs Rate of Post-Cataract Infectious Endophthalmitis 2009-… Linear (Rate of Post-Cataract Infectious Endophthalmitis… Table 1: Harm Score in Reports of Post-Cataract Endophthalmitis Events (N= 174) Figure 2: Frequency by Age
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