Surgical wound infection rates, obtained by comprehensive sur-veillance programmes, are considered to be important qualityassurance indicators. There is evidence that reporting of infectionrates to and action by individual surgeons and hospital managerscan result in sustained reductions in infection rates over time.1However, surveillance programmes confined to only detectinginfections that develop in patients prior to their discharge willsignificantly underestimate infection rates. In this edition of the Journal, Kent et al. present data obtained from a Victorianprivate hospital2 which confirms the findings of previous studiesthat the majority of surgical wound infections are detected only bypost-discharge surveillance.3

Thus post-discharge surgical wound surveillance is important, yetit appears that only 12% of Australian hospitals ever perform it oneven a semiregular basis.4 Why is this? One reason is that there isno established standardized methodology for performing post-discharge surveillance. Kent et al. used mail-back surgeon ques-tionnaires (with telephone reminders and medical record review asa back-up);2 others have used patient questionnaires or phonesurveys, or a combination of methods.5 Most authorities recom-mend that a combination of methods be used for maximum sen-sitivity in detecting cases.5 Because each hospital’s follow-uppatterns will differ, methodology will need to be individualized.There is still no national standardized methodology for performingnosocomial infection surveillance in Australia but a Federalgovernment Working Party is currently trying to develop con-sensus guidelines that should include methodology for surgical sitepost-discharge surveillance.

Another reason why post-discharge surveillance is not morewidely performed is the particular labour intensiveness andexpense of this form of surveillance. Kent et al. achieved animpressive 98.8% follow-up rate and present data that suggest that thevalidity of infection rates would be suspect if the follow-up rate is < 80%.2 They also recommend that regulatory bodies, as part ofany national surveillance system, set minimum follow-up rates.The high follow-up rate was achieved by Infection Control staffringing non-responding surgeons’ practices up to three times andretrieving and reviewing medical records. This process is timeconsuming and hence expensive. For example, Reimer et al. estimatedthat the use of phone surveys for performing post-discharge sur-veillance would require 30 person-hours per week per 100 proceduressurveyed.6 Few Australian hospitals have the recommended one infection control practitioner per 250 beds suggested as theminimum staff level required to perform ‘routine’ infection controlduties,7 let alone conduct post-discharge surveillance programmes.

Infections that develop following discharge tend to be lesssevere than those that develop in hospital8 and unplanned re-admissions for treatment are required only in a minority ofcases. Thus the cost of managing post-discharge infections isborne largely by the community rather than by the hospital,raising questions on the cost-effectiveness of hospitals conductingpost-discharge surveillance. Hospital managers will need to be con-vinced of the value of post-discharge surveillance despite itscost and allocate sufficient resources so that valid data can beobtained.

There are significant obstacles to overcome before post-discharge surveillance is performed routinely on a regular basis byAustralian hospitals. Yet we must move towards this goal if we aregoing to be serious about improving the quality of surgical carewithin our hospitals.

REFERENCES1. Olson M, Lee J. Continuous 10 year wound infection surveil-

lance. Arch. Surg. 1990; 125: 794–803.2. Kent P, McDonald M, Harris O, Mason T, Spelman D. Post-

discharge surgical wound infection surveillance in a provincialhospital: Follow-up rates, validity of data and review of the liter-ature. ANZ J. Surg. 2001; 71: 583–9.

3. Society for Hospital Epidemiology of America; Association forPractitioners in Infection Control; Surgical Infection Society.Consensus paper on the surveillance of surgical wound infec-tion. Infect. Control Hosp. Epidemiol. 1992; 13: 599–605.

4. Murphy C, McLaws M-L. Methodologies used in surveillance ofsurgical wound infection and bacteremia in Australian hospi-tals. Am. J. Infect. Control 1999; 27: 474–81.

5. Holtz T, Wenzel R. Postdischarge surveillance for nosocomialwound infection: A brief review and commentary. Am. J. Infect.Control 1992; 20: 206–13.

6. Reimer K, Gleed C, Nicolle L. The impact of postdischargesurveillance on surgical wounds. Todays OR Nurse 1987; 9:31–6.

7. Association for Professionals in Infection Control and Epidemi-ology. Infection Control and Applied Epidemiology. St Louis:Mosby, 1996.

8. Mitchell D, Swift G, Gilbert G. Surgical wound infection sur-veillance: The importance of infections that develop after hospitaldischarge. Aust. N.Z. J. Surg. 1999; 69: 117–20.

Centre for Infectious Diseases DAVID H. MITCHELL

and MicrobiologyWestmead Hospital, Westmead, NSW

ANZ J. Surg. (2001) 71, 563

EDITORIAL

POST-DISCHARGE SURGICAL WOUND SURVEILLANCE

Editorials in this issue

• Post-discharge surgical wound surveillance 563

• Consensus statement 564