Surgical Site Infection Outbreak in Spinal Surgery: A Systematic Investigation Using Mutually Exclusive and...

Area of Science:

• Infectious Diseases
• Surgical Outcomes
• Healthcare Quality Improvement

Background:

• Surgical site infections (SSIs) are a persistent challenge in spinal surgery.
• An unusual outbreak occurred at an institution with previously low SSI rates.
• This investigation focused on identifying the root cause of the unexpected increase in SSIs.

Purpose of the Study:

• To investigate an outbreak of surgical site infections (SSIs) following spinal surgery.
• To identify the contributing factors to the increased SSI rate.
• To evaluate the effectiveness of a systematic investigation approach.

Main Methods:

• A comprehensive Mutually Exclusive and Collectively Exhaustive (MECE) analysis was employed.
• Investigated pre-operative, intra-operative, and post-operative factors.
• Statistical analysis, including Fisher exact test, was used to compare groups.

Main Results:

• An outbreak of 6 SSIs in 84 procedures (7.1%) occurred, compared to a baseline of 0.3%.
• All SSIs were caused by skin commensal organisms and occurred within 8 days post-operatively.
• A significant association was found between SSIs and novice technicians (<6 months experience) in smaller operating rooms (100% vs. 10.3%, p < 0.001).

Conclusions:

• Conventional risk factor analysis was insufficient to identify the outbreak's cause.
• Systematic MECE analysis revealed staff-related factors as critical.
• Targeted staff training interventions successfully reduced SSI rates to baseline levels, highlighting vulnerability to process failures.