Results of a comprehensive quality improvement program to prevent surgical site infection in targeted case types: Inadvertent reduction of spinal surgery infection rates

Abstract

BACKGROUND: In 2003, a 586-bed facility began a quality improvement initiative to prevent surgical site infection (SSI) in targeted case types. We present the incidental and dramatic decrease across the spinal surgery population as a result of this initiative. OBJECTIVES: The results of this program were used to identify and correct system problems and apply successful processes across all surgical populations for future SSI prevention efforts. METHODS: Pre-intervention data were collected on 1202 spinal surgery patients in 2003. In addition to traditional surveillance, indicators monitored included timing of prophylactic antibiotic administration prior to incision, prophylactic antibiotic selection, discontinuation of prophylactic antibiotic, maintenance of normothermia and glucose in all operative phases, method of hair removal, and site preparation. A multidisciplinary SSI prevention team analyzed monthly infection rates and compliance with indicators and also led process development, implementation, and evaluation efforts. Monthly reporting of SSI indicator compliance was shared with all medical and surgical process improvement committees. In 2004, 1524 cases were followed after process improvements were implemented in spinal surgeries. Interventions focused in the peri-operative period and included pre-admission and peri-operative chlorohexidine scrubs, discontinuation of shaving operative sites, administration of prophylactic antibiotics by the anesthetist, discontinuation of prophylactic antibiotic within 24 hours, and supporting normothermia of the patient. RESULTS: Findings demonstrated that SSI rates were reduced across surgical services. Though cases were not stratified by national nosocomial risk indices, overall mean rates for post-intervention surgeries fell well below the national average. The cumulative reduction of SSI by the end of 2004 was 14%, with a significant decrease of 37% found in spinal surgeries. Reductions in spinal surgeries remained significant even when adjusting for confounding variables such as patient characteristics and wound classifications. CONCLUSION: Implementation of a comprehensive approach to reduce SSI was successful, specifically in spinal procedures. More research is needed to consider additional prevention strategies for spinal surgery SSI such as surgical equipment, glue, approach, and level of operative areas of the spine.