Clinical Immersion Project Development Part B/ Also order Part A


1.Conduct a review of the literature related to Post-Infection in Total Knee Arthroplasty  clinical site VA Hospital. Limit search to the last 5yrs. Databases may include, but are not limited to, PubMed, CINAHL, ProQuest, and Cochrane Systematic Reviews. Synthesize essential findings from your review of the literature: What is known? Where are the gaps? What findings or recommend will support your project? 2.Locate evidence-based guidelines or best practices related to your identified problem and delineate components of the selected guidelines/best to guide the project. 3.Identify the performance improvement goals for the patient cohort. What are the anticipated outcomes of the project/ goals must be measurable.


Clinical Immersion Project

   Question 1

Post infection following a total knee arthroplasty has received great attention over the years. Numerous researches have focused on establishing the root causes of post infection following a Total Knee Arthroplasty procedure, and ways of minimizing patient risks. Singh (2011) carried out a detailed meta-analysis to examine the impacts of smoking on post-infection risk following a total knee arthroplasty. The study involved analysis of past researches that were conducted in full and results published. The study concludes that there is a significant risk of developing post infections among current smokers following total knee arthroplasty compared to non-smokers. According to the study, current smokers are up to 32 percent more likely to develop post-infection compared to non-smokers. Knowledge gaps were however identified in the studies. For instance, majority of the studies did not investigate whether the duration of smoking and the amount of smoking impacts post-operation infections.

Namba, Inacio, & Paxton, (2013) carried out a retrospective study to identify the risk factors associated with a post-infection following a total knee arthroplasty. Data for the study was obtained from a cohort of patients who underwent knee arthroplasty between 2001 and 2009. The results indicated that certain factors predispose patients to post-infections in total knee arthroplasty. Factors which had the highest rating include the BMI of a patient, diabetes mellitus osteonecrosis and presence of posttraumatic arthritis. In addition, men were more likely than women to acquire surgical site infections. The findings of the study indicate that an effective post-operation infection surveillance system should be used to monitor patients who have undergone total knee arthroplasty.


Question 2

There are particular evidence based guidelines related to post-infection in total knee arthroplasty. The use of antibiotics in the irrigation solution has been found to be quite effective in reducing incidences of post—infection. Prophylaxis is the commonly used antibiotic although it is commonly administered intravenously to patients. According to Namba, Inacio, & Paxton (2013), mixing prophylactic antibiotics with the irrigation fluid can also help in reducing the incidences of post-infections among patients. The length of operation period significantly impacts the risk of post-infection in total knee replacement. Vast research indicates that the more time the operation takes the higher the risks of a post-infection. It is thus important to complete the procedure in the least time possible to decrease the risk of a post-infection.

Post-infection in total knee arthroplasty is also determined by the hospital factors (Thornley et al., 2015). Congested hospitals increase the risk of post-infection in total knee arthroplasty. Low-volume hospitals have a relatively low risk of a post-infection. This was revealed following an analysis of post infection data between hospitals in urban centers and those in rural areas. The latter had a higher incidence of post-infection compared to the rural areas which are less congested. An infection surveillance system, as earlier mentioned may also be effective in helping identify cases of post-infection early before they cause serious complications on the patient. Revision of the procedure also increases the risk of a post-infection. A two-stage revision may significantly increase the risk of a post-infection in total knee replacement. Lastly, majority of studies indicate that the use of antibiotic-laden cement may not be effective in reducing the risks of post-infection in total knee arthroplasty. In fact, it has been observed that antibiotic-laden cement may increase the risk of a post-infection.


Question 3

The major aim or goal off of the surgical team is to reduce incidences of post-infection among patients. In order to achieve this, particular performance improvement goals must be established. The first goal to be applied to patients suffering from a post-infection is the early detection of the infections. The hospital should be able to identify cases of infection within a period of one month by conducting necessary tests. Early detection will help reduce incidences of serious infections. The second goal is to reduce mortality rates resulting from total knee replacement procedures in the hospital. As earlier outlined, the use of prophylactic antibiotics has enormous positive benefits on the patients. In line with this, the goal of the hospital is to always commence administering prophylactic antibiotics within an hour of the surgical incision. Vancomycin should also be administered two hours before the procedure since it takes more infusion time.

The anticipated outcomes of the project is to reduce post-infection in total knee arthroplasty by more than half. Statistics indicate that about 1.8 percent of patients who undergo total knee arthroplasty develop deep infections. The risks of developing deep infections are particularly higher among patients suffering from diabetes mellitus. This is believed to be the result of their compromised immune system. Post-infection in total knee arthroplasty may develop between one month and three months. The infection may arise during the operation or during the recovery period possibly from other parts of the body or direct contamination of the incision area. Infections may also spread from another part of the day.


Namba, R. S., Inacio, M. S., & Paxton, E. W. (2013). Risk factors associated with deep surgical   site infections after primary total knee arthroplasty. Journal Of Bone & Joint Surgery, American Volume, 95-A(9), 775-782.

Singh, J. A. (2011). Smoking and Outcomes after Knee and Hip Arthroplasty: A Systematic         Review. The             Journal of Rheumatology38(9), 1824–1834.  

Thornley, P., Evaniew, N., Riediger, M., Winemaker, M., Bhandari, M., & Ghert, M. (2015).             Postoperative antibiotic prophylaxis in total hip and knee arthroplasty: a systematic           review and meta-analysis of randomized controlled trials. CMAJ Open3(3), E338–E343.   


Data Management-Fishbone diagrams

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