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A standardized protocol to reduce pediatric spine surgery infection: a quality improvement initiative
Sheila L Ryan1, Anish Sen, Kristen Staggers
1Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.
Insights
A new protocol significantly reduced complex spine surgery infection rates in pediatric patients. This quality improvement initiative led to a decrease from an average of 5.8% to 2.2% infection rates, enhancing patient safety.
Area of Science:
- Pediatric Surgery
- Infectious Disease Control
- Quality Improvement in Healthcare
Background:
- Complex (instrumented) spine infections pose a significant risk in pediatric patients undergoing spinal fusion.
- High-volume institutions require standardized protocols to manage and reduce infection rates.
- Previous institutional experience and current literature informed the development of a new protocol.
Purpose of the Study:
- To develop and implement a standardized protocol to reduce the surgical site infection (SSI) rate in pediatric patients undergoing complex spine surgery.
- To prospectively evaluate the effectiveness of the implemented protocol in a high-volume pediatric spine surgery setting.
Main Methods:
- A multidisciplinary team developed a standardized protocol based on literature review and institutional experience.
- The protocol was prospectively applied to all pediatric patients undergoing complex spine surgery from August 2012.
- Infection rates and procedure data were collected and compared before and after protocol implementation.
Main Results:
- The institutional infection rate decreased from an average of 5.8% (range 3.4%-8.9%) pre-protocol to 2.2% post-protocol (p = 0.0362).
- A total of 267 procedures were performed, with 6 infections (2.2%) recorded after protocol implementation.
- Compliance with data collection was 63.7%, with lower compliance noted in cases with infections.
Conclusions:
- The standardized protocol effectively reduced surgical site infections in pediatric complex spine surgery.
- Protocol compliance was generally good, but identified areas for refinement.
- Further analysis of factors associated with post-operative wound infections can optimize future protocol iterations.
Object:
Quality improvement methods are being implemented in various areas of medicine. In an effort to reduce the complex (instrumented) spine infection rate in pediatric patients, a standardized protocol was developed and implemented at an institution with a high case volume of instrumented spine fusion procedures in the pediatric age group.
Methods:
Members of the Texas Children's Hospital Spine Study Group developed the protocol incrementally by using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied to all children undergoing complex spine surgery starting August 21, 2012. Acute infections were defined as positive wound cultures within 12 weeks of surgery, defined in alignment with current hospital infection control criteria. Procedures and infections were measured before and after protocol implementation. This protocol received full review and approval of the Baylor College of Medicine institutional review board.
Results:
Nine spine surgeons performed 267 procedures between August 21, 2012, and September 30, 2013. The minimum follow-up was 12 weeks. The annual institutional infection rate prior to the protocol (2007-2011) ranged from 3.4% to 8.9%, with an average of 5.8%. After introducing the protocol, the infection rate decreased to 2.2% (6 infections of 267 cases) (p = 0.0362; absolute risk reduction 3.6%; relative risk 0.41 [95% CI 0.18-0.94]). Overall compliance with data form completion was 63.7%. In 4 of the 6 cases of infection, noncompliance with completion of the data collection form was documented; moreover, 2 of the 4 spine surgeons whose patients experienced infections had the lowest compliance rates in the study group.
Conclusions:
The standardized protocol for complex spine surgery significantly reduced surgical site infection at the authors' institution. The overall compliance with entry into the protocol was good. Identification of factors associated with post-spine surgery wound infection will allow further protocol refinement in the future.
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