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A Novel Prevention Bundle to Reduce Surgical Site Infections in Pediatric Spinal Fusion Patients

Published online by Cambridge University Press:  28 January 2016

Jane M. Gould ,
Patricia Hennessey ,
Andrea Kiernan ,
Shannon Safier  and
Martin Herman
Jane M. Gould*
Affiliation:
Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania Section of Infectious Diseases, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania
Patricia Hennessey
Affiliation:
Infection Prevention, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania
Andrea Kiernan
Affiliation:
Infection Prevention, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania
Shannon Safier
Affiliation:
Orthopedic Surgery, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania
Martin Herman
Affiliation:
Orthopedic Surgery, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania
*
Address correspondence to Jane M. Gould, MD, Section of Pediatric Infectious Diseases, St. Christopher’s Hospital for Children, 160 E. Erie Ave, Philadelphia, PA 19134 (jane.gould@drexelmed.edu).
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Abstract

BACKGROUND

The Surgical Care Improvement Project bundle emphasizes operative infection prevention practices. Despite implementing the Surgical Care Improvement Project bundle in 2008, spinal fusion surgical site infections (SF-SSI) continued to be prevalent for this low-volume, high-risk surgery.

OBJECTIVE

To design a combined pre-, peri-, and postoperative bundle (PPPB) that would lead to sustained reductions in SF-SSI rates.

DESIGN

Quality improvement project, before-after trial with cost-effectiveness analysis.

SETTING

Children’s hospital.

PATIENTS

All spinal fusion patients, 2008–2015.

INTERVENTION

A multidisciplinary team developed the PPPB composed of Surgical Care Improvement Project elements plus improved wound care practices, nursing standard of care, dedicated nursing unit, dermatology assessment tool and consultation, nursing education tool using “teach back” technique, and a “Back Home” kit. SF-SSI rates were compared before (2008–2010) and after (2011-February 2015) implementation of PPPB. PPPB compliance was monitored.

RESULTS

A total of 224 SF surgeries were performed from 2008 to February 2015. Pre-PPPB analysis revealed median time to SF-SSI of 28 days, secondary to skin and bowel flora. Mean 3-year pre-PPPB SF-SSI rate per 100 SF surgeries was 8.2 (8/98) (2008: 13.3 [4/30], 2009: 2.7 [1/37], 2010: 9.7 [3/31]). Mean SF-SSI rate after PPPB was 2.4 (3/126) (January 2011-February 2015); there was a 71% reduction in mean SSI rate (P=.0695). No SF-SSI occurred in neuromuscular patients (P=.008) after PPPB. Compliance with PPPB elements has been 100%.

CONCLUSIONS

PPPB led to sustained improvement in SF-SSI rates over 50 months. The PPPB could be reproduced for other surgeries.

Infect Control Hosp Epidemiol 2016;37:527–534

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 37 , Issue 5 , May 2016 , pp. 527 - 534
Copyright
© 2016 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Footnotes

Presented in part: Pediatric Academic Societies Annual Meeting; Washington, DC; May 4, 2013 (Abstract 751654).

References

REFERENCES

1. Pennsylvania Health Care Cost Containment Council. The impact of healthcare-associated infections in Pennsylvania. Pennsylvania Health Care Cost Containment Council website. http://www.phc4.org/reports/hai. Published 2012. Accessed January 10, 2016.Google Scholar
2. Kirkland, KB, Briggs, JP, Trivette, SL, Wilkinson, WE, Sexton, DJ. The impact of surgical site infections in the 1990s: attributable mortality, excess length of hospitalization and extra costs. Infect Control Hosp Epidemiol 1999;20:725–730.Google Scholar
3. Calderone, RR, Garland, DE, Capen, DA, Oster, H. Cost of medical care for postoperative spinal infections. Orthop Clin North Am 1996;27:171–182.Google Scholar
4. Smith, JS, Shaffrey, CI, Sansur, CA, et al. Rates of infection after spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society morbidity and mortality committee. Spine 2011;36:556–563.CrossRefGoogle ScholarPubMed
5. Labbe, AC, Demers, AM, Rodrigues, R, Arlet, V, Tanguay, K, Moore, DL. Surgical site infection following spinal fusion: a case control study in a children’s hospital. Infect Control Hosp Epidemiol 2003;24:591–595.Google Scholar
6. Association of Professionals in Infection Control and Hospital Epidemiology (APIC). Guide to the elimination of orthopedic surgical site infections. APIC website. http://www.apic.org/Resource_/EliminationGuideForm/34e03612-d1e6-4214-a76b-e532c6fc3898/File/APIC-Ortho-Guide.pdf. Published 2010. Accessed January 10, 2016.Google Scholar
7. Rao, SB, Vasquez, G, Harrop, J, et al. Risk factors for surgical site infections following spinal fusion procedures: a case-control study. Clin Infect Dis 2011;53:686–692.Google Scholar
8. Milstone, AM, Maragakis, LL, Townsend, T, et al. Timing of preoperative antibiotic prophylaxis: a modifiable risk factor for deep surgical site infections after pediatric spinal fusion. Pediatr Infect Dis 2008;27:704–708.Google Scholar
9. Mackenzie, WG, Matsumato, H, Williams, BA. Surgical site infection following spinal instrumentation for scoliosis: a multicenter analysis of rates, risk factors, and pathogens. J Bone Joint Surg Am 2013;95:800–806.CrossRefGoogle ScholarPubMed
10. Cahill, PJ, Warnick, DE, Lee, MJ, et al. Infection after spinal fusion for pediatric spinal deformity: thirty years of experience at a single institution. Spine 2010;35:1211–1217.Google Scholar
11. Anderson, DJ, Podgorny, K, Berrios-Torres, SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:605–627.Google Scholar
12. Bratzler, DW, Hunt, DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patient having surgery. Clin Infect Dis 2006;43:322–330.Google Scholar
13. Berenquer, CM, Ochsner, MG, Lord, SA, Senkowski, CK. Improving surgical site infections: using national surgical quality improvement program data to institute surgical care improvement project protocols in improving surgical outcomes. J Am Coll Surg 2012;210:737–741.Google Scholar
14. Nguyen, N, Yegiyants, S, Kaloostian, C, Abbas, MA, Difronzo, LA. The Surgical Care Improvement Project (SCIP) initiative to reduce infection in elective colorectal surgery: which performance measures affect outcome? Am Surg 2008;74:1012–1016.Google Scholar
15. Stevens, DB, Beard, C. Segmental spinal instrumentation for neuromuscular spinal deformity. Clin Orthop Relat Res 1989;242:164–168.Google Scholar
16. Murphy, NA, Firth, S, Jorgensen, T, Young, PC. Spinal surgery in children with idiopathic and neuromuscular scoliosis: what’s the difference? J Pediatr Orthop 2006;26:216–220.Google Scholar
17. Richards, BS. Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg Am 1995;77:524–529.CrossRefGoogle ScholarPubMed
18. Clark, CE, Shufflebarger, HL. Late-developing infection in instrumented idiopathic scoliosis. Spine 1999;24:1909–1912.Google Scholar
19. Ho, C, Sucato, DJ, Richards, BS. Risk factors for the development of delayed infections following posterior spinal fusion and instrumentation in adolescent idiopathic scoliosis patients. Spine 2007;32:2272–2277.Google Scholar
20. Coe, JD, Arlet, V, Donaldson, W, et al. Complications in spinal fusion for adolescent idiopathic scoliosis in the new millennium: a report of the Scoliosis Research Society morbidity and mortality committee. Spine 2006;31:345–349.Google Scholar
21. Guigui, P, Blamoutier, A, Groupe d’Etude de la Scoliose. Complications of surgical treatment of spinal deformities: a prospective multicentric study of 3311 patients [in French]. Rev Chir Orthop Reparatrice Appar Mot 2005;91:314–327.CrossRefGoogle ScholarPubMed
22. Sansur, CA, Reames, DL, Smith, JS, et al. Morbidity and mortality in the surgical treatment of 10,242 adults with spondylolisthesis. J Neurosurg Spine 2010;13:589–593.Google Scholar
23. Sponseller, PD, LaPorte, DM, Hungerford, MW, Eck, K, Bridwell, KH, Lenke, LG. Deep wound infections after neuromuscular scoliosis surgery: a multicenter study of risk factors and treatment outcomes. Spine 2000;25:2461–2466.Google Scholar
24. Karki, S, Cheng, AC. Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infection and colonization with multi-resistant organisms: a systematic review. J Hosp Infect 2012;82:71–84.Google Scholar
25. Vitale, MG, Riedel, MD, Glotzbecker, MP, et al. Building consensus: development of a best practice guideline for surgical site infection prevention in high-risk pediatric spine surgery. J Pediatr Orthop 2013;33:471–478.Google Scholar
26. Milstone, AM, Passaretti, CL, Perl, TM. Chlorhexidine: expanding the armamentarium for infection control and prevention. Clin Infect Dis 2008;46:274–281.Google Scholar
27. Aziz, Z, Abu, SF, Chong, NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns 2012;38:307–318.CrossRefGoogle ScholarPubMed
28. Khundkar, R, Malic, C, Burge, T. Use of acticoat dressings in burns: what is the evidence? Burns 2010;36:751–758.Google Scholar
29. Epstein, N. Do silver-impregnated dressings limit infections after lumbar laminectomy with instrumented fusion? Surg Neurol 2007;68:483–485.Google Scholar
30. Bowler, PG, Welsby, S, Hogarth, A, Towers, V. Topical antimicrobial protection of postoperative surgical sites at risk of infection with Propionibacterium acnes: an in-vitro study. J Hosp Infect 2013;88:232–237.CrossRefGoogle Scholar
31. Heggers, J, Goodheart, RE, Washington, J, et al. Therapeutic efficacy of three silver dressings in an infected animal model. J Burn Care Rehabil 2005;26:53–56.Google Scholar
32. Krieger, BR, Davis, DM, Sanchez, JE, et al. The use of silver nylon in preventing surgical site infections following colon and rectal surgery. Dis Colon Rectum 2011;54:1014–1019.Google Scholar
33. Pozza, M, Matthew, P, Lunardi, F. Experience in treating combat burns in Afghanistan by using silver-nylon dressing. J Spec Oper Med 2014;14:1–5.Google Scholar
34. Ballard, MR, Miller, NH, Nyquist, AC, Elise, B, Baulesh, DM, Erickson, MA. A multidisciplinary approach improves infection rates in pediatric spine surgery. J Pediatr Orthop 2012;32:266–270.Google Scholar
35. Skoufalos, A, Clarke, JL, Napp, M, et al. Improving awareness of best practices to reduce surgical site infection: a multistakeholder approach. Am J Med Qual 2012;27:297–304.Google Scholar
36. Fukuda, H, Imanaka, Y, Hirose, M, Hayashida, K. Factors associated with system-level activities for patient safety and infection control. Health Policy 2009;89:26–36.Google Scholar
37. Hanacik, LJ, Franson, TR, Gollup, JD, Rytel, MW. Implementing a successful hepatitis B vaccination program. Infect Control 1985;6:306–309.Google Scholar
38. Perencevich, EN, Stone, PW, Wright, SB, et al. Raising standards while watching the bottom line: making a business case for infection control. Infect Control Hosp Epidemiol 2007;28:1121–1133.Google Scholar
39. Nandyala, SV, Schwend, RM. Prevalence of intraoperative tissue bacterial contamination in posterior pediatric spinal deformity surgery. Spine 2013;38:E482–E486.Google Scholar
40. Ramli, R, Malik, A, Hani, A, Jamil, A. Acne analysis, grading and computational assessment methods: an overview. Skin Res Technol 2012;18:1–14.Google Scholar