Reducing Surgical Site Infection in Pediatric Scoliosis Surgery: A Multidisciplinary Improvement Program and Prospective 4-Year Audit

Study Design: Single-center prospective cohort. Objectives: To evaluate a multidisciplinary led, structured protocol for reducing surgical site infections (SSIs) in pediatric scoliosis surgery. Methods: Following a spike to 8.6% in local annual infection rate, a multidisciplinary team was convened to identify interventions. The team consisted of spinal surgeons, infectious diseases consultants, physiotherapists, specialist nurses, and theatre managers. A protocol was initiated, including preoperative skin decontamination; standardized operative site prepreparation; betadine-soaked swabs sutured to wound edges; blood loss minimization; 3 L0.9% saline pulsed-lavage; defined protocol of glove changes; antibiotic regime of preoperative gentamicin, intraoperative subfascial vancomycin powder, 48-hour cefuroxime; and intraoperative normothermia. A 4-year audit was initiated of all patients aged ≤18 years undergoing corrective spinal deformity surgery. Institutional board review was not required. Results: Between January 1, 2014 and January 1, 2018, 414 operations were performed on 355 patients: male:female = 1:2.2, mean age 13.7 years (range 2.5-17.9), 233 idiopathic (mean operated vertebral levels 12), 122 neuromuscular (mean operated vertebral levels 14), 66 growing rod procedures, 41 multistage procedures. The mean number of operated vertebral levels both overall and in infected cases was 13 (range 2-17). Nine SSIs occurred in 8 patients at 3 months (4 neuromuscular), resulting in an overall SSI per operation of 2.2%. Conclusion: A multidisciplinary approach with standardized measures significantly reduced SSIs in the unit’s pediatric scoliosis surgery.

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Characteristics of false-positive alerts on transcranial motor evoked potential monitoring during pediatric scoliosis and adult spinal deformity surgery: an “anesthetic fade” phenomenon

Journal of Neurosurgery Spine ◽

10.3171/2019.9.spine19814 ◽

2020 ◽

Vol 32 (3) ◽

pp. 423-431 ◽

Cited By ~ 3

Author(s):

Hiroki Ushirozako ◽

Go Yoshida ◽

Tomohiko Hasegawa ◽

Yu Yamato ◽

Tatsuya Yasuda ◽

...

Keyword(s):

Spinal Deformity ◽

False Positive ◽

Adult Spinal Deformity ◽

False Positive Rate ◽

Multivariate Logistic Regression Analysis ◽

Motor Evoked Potential ◽

Scoliosis Surgery ◽

True Negative ◽

Duration Of Surgery ◽

Spinal Deformity Surgery

OBJECTIVETranscranial motor evoked potential (TcMEP) monitoring may be valuable for predicting postoperative neurological complications with a high sensitivity and specificity, but one of the most frequent problems is the high false-positive rate. The purpose of this study was to clarify the differences in the risk factors for false-positive TcMEP alerts seen when performing surgery in patients with pediatric scoliosis and adult spinal deformity and to identify a method to reduce the false-positive rate.METHODSThe authors retrospectively analyzed 393 patients (282 adult and 111 pediatric patients) who underwent TcMEP monitoring while under total intravenous anesthesia during spinal deformity surgery. They defined their cutoff (alert) point as a final TcMEP amplitude of ≤ 30% of the baseline amplitude. Patients with false-positive alerts were classified into one of two groups: a group with pediatric scoliosis and a group with adult spinal deformity.RESULTSThere were 14 cases of false-positive alerts (13%) during pediatric scoliosis surgery and 62 cases of false-positive alerts (22%) during adult spinal deformity surgery. Compared to the true-negative cases during adult spinal deformity surgery, the false-positive cases had a significantly longer duration of surgery and greater estimated blood loss (both p < 0.001). Compared to the true-negative cases during pediatric scoliosis surgery, the false-positive cases had received a significantly higher total fentanyl dose and a higher mean propofol dose (0.75 ± 0.32 mg vs 0.51 ± 0.18 mg [p = 0.014] and 5.6 ± 0.8 mg/kg/hr vs 5.0 ± 0.7 mg/kg/hr [p = 0.009], respectively). A multivariate logistic regression analysis revealed that the duration of surgery (1-hour difference: OR 1.701; 95% CI 1.364–2.120; p < 0.001) was independently associated with false-positive alerts during adult spinal deformity surgery. A multivariate logistic regression analysis revealed that the mean propofol dose (1-mg/kg/hr difference: OR 3.117; 95% CI 1.196–8.123; p = 0.020), the total fentanyl dose (0.05-mg difference; OR 1.270; 95% CI 1.078–1.497; p = 0.004), and the duration of surgery (1-hour difference: OR 2.685; 95% CI 1.131–6.377; p = 0.025) were independently associated with false-positive alerts during pediatric scoliosis surgery.CONCLUSIONSLonger duration of surgery and greater blood loss are more likely to result in false-positive alerts during adult spinal deformity surgery. In particular, anesthetic doses were associated with false-positive TcMEP alerts during pediatric scoliosis surgery. The authors believe that false-positive alerts during pediatric scoliosis surgery, in particular, are caused by “anesthetic fade.”

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Surgical site infection metrics: Dissecting the differences between the National Health and Safety Network and the National Surgical Quality Improvement Program

Antimicrobial Stewardship & Healthcare Epidemiology ◽

10.1017/ash.2021.176 ◽

2021 ◽

Vol 1 (1) ◽

Author(s):

Alaia M. M. Christensen ◽

Karen Dowler ◽

Shira Doron

Keyword(s):

Quality Improvement ◽

Health And Safety ◽

Surgical Site Infections ◽

Cost Of Care ◽

Quality Improvement Program ◽

Surveillance Systems ◽

Improvement Program ◽

Surgical Quality ◽

National Healthcare Safety Network ◽

Hospital Acquired

Abstract Surgical site infections (SSIs) are associated with readmissions, reoperations, increased cost of care, and overall morbidity and mortality risk. The National Healthcare Safety Network (NHSN) and the National Surgical Quality Improvement Program (NSQIP) have developed an array of metrics to monitor hospital-acquired complications. The only metric collected by both is SSI, but performance as benchmarked against peer hospitals is often discordant between the 2 systems. In this commentary, we outline the differences between these 2 surveillance systems as they relate to this potential for discordance.

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The Use of Vancomycin Powder for Surgical Prophylaxis Following Craniotomy

Neurosurgery ◽

10.1093/neuros/nyw127 ◽

2017 ◽

Vol 80 (5) ◽

pp. 754-758 ◽

Cited By ~ 17

Author(s):

Vinod Ravikumar ◽

Allen L. Ho ◽

Arjun V. Pendharkar ◽

Eric S. Sussman ◽

Kevin Kwong-hon Chow ◽

...

Keyword(s):

Ad Hoc ◽

Cost Savings ◽

Surgical Site Infections ◽

Control Group ◽

Infection Prophylaxis ◽

Potential Cost Saving ◽

Infection Rates ◽

Surgical Prophylaxis ◽

Potential Cost ◽

Vancomycin Powder

Abstract BACKGROUND: Intrawound vancomycin powder has been studied extensively in spinal fusion surgeries and been found to reduce rates of surgical site infections (SSIs) significantly. Despite its success in spinal surgeries, topical vancomycin has not been extensively studied with respect to cranial neurosurgery. OBJECTIVE: To evaluate the efficacy of intrawound topical vancomycin for prevention of SSIs following open craniotomies. METHODS: We retrospectively analyzed a large series of 350 patients from 2011 to 2015 in a pre/postintervention study of use of topical vancomycin to reduce postoperative craniotomy infection rates. We had a preintervention control group of 225 patients and a postintervention group of 125 patients that received intrawound topical vancomycin. RESULTS: Our preintervention incidence of SSI was 2.2% and this was significantly reduced to 0% following introduction of topical vancomycin (P < .5). An ad hoc cost analysis suggested a cost savings of ${\$}$59 965 with the use of topical vancomycin for craniotomies. CONCLUSION: Our study found a significant reduction in SSI rates after introduction of topical vancomycin. Thus, this simple intervention should be considered in all open craniotomy patients as both infection prophylaxis and a potential cost saving intervention.

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Reducing surgical site infections following craniotomy: examination of the use of topical vancomycin

Journal of Neurosurgery ◽

10.3171/2014.12.jns142092 ◽

2015 ◽

Vol 123 (6) ◽

pp. 1600-1604 ◽

Cited By ~ 33

Author(s):

Kalil G. Abdullah ◽

Mark A. Attiah ◽

Andrew S. Olsen ◽

Andrew Richardson ◽

Timothy H. Lucas

Keyword(s):

Primary Outcome ◽

Surgical Site Infections ◽

Primary Outcome Measure ◽

Secondary Outcome ◽

Time Interval ◽

Infection Rates ◽

Skin Flora ◽

Vancomycin Powder ◽

Subgaleal Space ◽

Typical Skin

OBJECT Although the use of topical vancomycin has been shown to be safe and effective for reducing postoperative infection rates in patients after spine surgery, its use in cranial wounds has not been studied systematically. The authors hypothesized that topical vancomycin, applied in powder form directly to the subgaleal space during closure, would reduce cranial wound infection rates. METHODS A cohort of 150 consecutive patients who underwent craniotomy was studied retrospectively. Seventy-five patients received 1 g of vancomycin powder applied in the subgaleal space at the time of closure. This group was compared with 75 matched-control patients who were accrued over the same time interval and did not receive vancomycin. The primary outcome measure was the presence of surgical site infection within 3 months. Secondary outcome measures included tissue pH from a subgaleal drain and vancomycin levels from the subgaleal space and serum. RESULTS Vancomycin was associated with significantly fewer surgical site infections (1 of 75) than was standard antibiotic prophylaxis alone (5 of 75; p < 0.05). Cultures were positive for typical skin flora species. As expected, local measured vancomycin concentrations peaked immediately after surgery (mean ± SD 499 ± 37 μg/ml) and gradually decreased over 12 hours. Vancomycin in the circulating serum remained undetectable. Subgaleal topical vancomycin was associated with a lower incidence of surgical site infections after craniotomy. The authors attribute this reduction in the infection rate to local vancomycin concentrations well above the minimum inhibitory concentration for antimicrobial efficacy. CONCLUSIONS Topical vancomycin is safe and effective for reducing surgical site infections after craniotomy. These data support the need for a prospective randomized examination of topical vancomycin in the setting of cranial surgery.

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What Is the Relationship between Operative Time and Adverse Events after Colon and Rectal Surgery?

The American Surgeon ◽

10.1177/000313481808400524 ◽

2018 ◽

Vol 84 (5) ◽

pp. 712-716 ◽

Cited By ~ 4

Author(s):

Gabriela Poles ◽

Caitlin Stafford ◽

Todd Francone ◽

Patricia L. Roberts ◽

Rocco Ricciardi

Keyword(s):

Colorectal Surgery ◽

Adverse Events ◽

Operative Time ◽

Primary Anastomosis ◽

Multivariable Analysis ◽

Rectal Surgery ◽

Surgical Site Infections ◽

Colon And Rectal Surgery ◽

Improvement Program ◽

Tract Infections

We propose that prolonged colorectal surgery operative times are associated with increased 30-day adverse events. We identified a cohort from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 2005 through December 2012. Patients who underwent colectomy with primary anastomosis were selected using CPT codes. Operative time was categorized into short, average, and long based on mean operative times 61 SD. NSQIP-approved multivariate models were used to identify associations between operative time and 30-day adverse events. A total of 113,615 patients underwent colorectal resection of which 46 per cent were laparoscopic and 12 per cent were identified as long operative times. Patients with long operative procedures had 34 per cent more superficial surgical site infections, 65 per cent more organ space infections, 69 per cent more abdominal dehiscences, 44 per cent more thrombotic complications, 45 per cent more urinary tract infections, 40 per cent more returns to the operating room, and 36 per cent more prolonged lengths of stay ( P < 0.05 for all analyses). The multivariable analysis revealed an association between long operative times and increased adverse events despite adjustment for all NSQIP recommended covariates. Our results reveal increased 30-day adverse events with increased operative time. We propose that operative time may serve as a proxy for surgical complexity in colorectal surgery.

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Surgical site infections in outpatient surgeries: Less invasive procedures contribute substantially to the overall burden

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.233 ◽

2019 ◽

Vol 40 (10) ◽

pp. 1191-1193

Author(s):

Katherine Linsenmeyer ◽

Westyn Branch-Elliman ◽

Emily Kalver ◽

Hillary J. Mull

Keyword(s):

Adverse Event ◽

Surgical Site Infections ◽

Outpatient Setting ◽

Veterans Affairs ◽

Site Infection ◽

Invasive Procedures ◽

Improvement Program ◽

Eligibility Criteria ◽

Surgical Quality

AbstractMore than 50% of outpatient surgeries predicted to have an increased likelihood of an adverse event were excluded from surgical site infection (SSI) surveillance based on Veterans Affairs Surgical Quality Improvement Program (VASQIP) eligibility criteria, defined by clinician determination of invasiveness. Burden of SSI for eligible versus ineligible surgeries was similar; thus, surveillance activities in the outpatient setting need to be re-evaluated.

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Root cause analysis of epidural spinal cord stimulator implant infections with resolution after implementation of an improved protocol for surgical placement

Journal of Infection Prevention ◽

10.1177/1757177419844323 ◽

2019 ◽

Vol 20 (4) ◽

pp. 185-190

Author(s):

Forest W Arnold ◽

Sarah Bishop ◽

David Johnson ◽

LaShawn Scott ◽

Crystal Heishman ◽

...

Keyword(s):

Spinal Cord ◽

Operating Room ◽

Surgical Site Infections ◽

Root Cause Analysis ◽

Hospital Epidemiology ◽

Cause Analysis ◽

Root Cause ◽

Cord Injury ◽

Vancomycin Powder ◽

To Receive

Background: Placing a spinal stimulator for the purpose of restoring paralysed function is a novel procedure; however, paralysis predisposes people to infection. Preventing surgical site infections is critical to benefit this population. Objective: The objective of this study was to review the root cause analysis of postoperative wound infections by a hospital epidemiology team following implantation of epidural spinal cord neurostimulators in patients with chronic spinal cord injury. Methods: A team was assembled to review the case of every individual who had been enrolled to receive a neurostimulator at the facility. A root cause analysis was performed evaluating five categories: the patient; equipment; facility/environment; procedure; and personnel. Findings: The root cause analysis included 11 patients. Two patients became infected. Three others dehisced their wound without becoming infected. All patients were given preoperative antibiotics on time. A mean of 17 personnel were in the operating room during surgery. Vancomycin powder was used in the patients who either dehisced their wound or became infected. Conclusions: The root cause analysis provides guidance for other institutions performing the same novel procedure. This analysis did not reveal a direct association, but did generate several areas for improvement including increasing pre-surgical screening, cleaning transient equipment (e.g., computer screens), limiting traffic in the operating room, using new sterile instruments for each stage of the procedure, not reopening the back incision, not applying vancomycin powder, and using an antimicrobial envelope for the stimulator.

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Derivation and Validation of the Surgical Site Infections Risk Model Using Health Administrative Data

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2015.327 ◽

2016 ◽

Vol 37 (4) ◽

pp. 455-465 ◽

Cited By ~ 3

Author(s):

Carl van Walraven ◽

Timothy D. Jackson ◽

Nick Daneman

Keyword(s):

Administrative Data ◽

Risk Model ◽

Surgical Site Infections ◽

Low Risk ◽

Primary Data ◽

Group Model ◽

Improvement Program ◽

Health Administrative Data ◽

Diagnostic Score ◽

Risk Patients

OBJECTIVESurgical site infections (SSIs) are common hospital-acquired infections. Tracking SSIs is important to monitor their incidence, and this process requires primary data collection. In this study, we derived and validated a method using health administrative data to predict the probability that a person who had surgery would develop an SSI within 30 days.METHODSAll patients enrolled in the National Surgical Quality Improvement Program (NSQIP) from 2 sites were linked to population-based administrative datasets in Ontario, Canada. We derived a multivariate model, stratified by surgical specialty, to determine the independent association of SSI status with patient and hospitalization covariates as well as physician claim codes. This SSI risk model was validated in 2 cohorts.RESULTSThe derivation cohort included 5,359 patients with a 30-day SSI incidence of 6.0% (n=118). The SSI risk model predicted the probability that a person had an SSI based on 7 covariates: index hospitalization diagnostic score; physician claims score; emergency visit diagnostic score; operation duration; surgical service; and potential SSI codes. More than 90% of patients had predicted SSI risks lower than 10%. In the derivation group, model discrimination and calibration was excellent (C statistic, 0.912; Hosmer-Lemeshow [H-L] statistic, P=.47). In the 2 validation groups, performance decreased slightly (C statistics, 0.853 and 0.812; H-L statistics, 26.4 [P=.0009] and 8.0 [P=.42]), but low-risk patients were accurately identified.CONCLUSIONHealth administrative data can effectively identify postoperative patients with a very low risk of surgical site infection within 30 days of their procedure. Records of higher-risk patients can be reviewed to confirm SSI status.Infect. Control Hosp. Epidemiol. 2016;37(4):455–465

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