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Implementing a Multidisciplinary Clinical Pathway Can Reduce the Deep Surgical Site Infection Rate After Posterior Spinal Fusion in High-Risk Patients

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Abstract

Design

Retrospective comparative study.

Objective

The purpose of this study is to measure SSI outcomes before and after implementation of our center’s multidisciplinary clinical pathway protocol for high-risk spinal surgery.

Background

Surgical site infections (SSIs) after spinal fusion harm patients and are associated with significant health care costs. Given the high rate of SSI in neuromuscular populations, there is a rationale to develop infection prevention strategies.

Methods

An institutional clinical pathway was created in 2012 and based on nationally published Best Practice Guidelines as well as hospital practices with a goal of reducing the rate of deep SSI in high-risk patients. Patient and procedure characteristics were compared prior to (2008–2011) and after (2012–2016) implementation of the pathway. Logistic regression using penalized maximum likelihood was used to assess differences in rate of infection before and after implementation.

Results

Cohorts of 132 and 115 high-risk patients were analyzed before and after pathway implementation. Rate of deep infections decreased from 8% to 1% of patients (p = .005). Preoperative antibiotics were dosed within 1 hour in 90% of the postpathway cohort. Redosing was successful in 94% of patients for first redose and 79% for second redose. Betadine irrigation was used in 76% of cases and vancomycin administered in 86%. Multivariable analysis determined that instances of compliant antibiotics dosing had 63% lower odds of infection compared with instances of noncompliance (p = .04).

Conclusions

Implementation of a multidisciplinary pathway aimed to reduce infection in patients at high risk for SSI after spinal fusion led to a significant reduction in deep SSI rate. It is impossible to attribute the drop in the deep SSI rate to any one factor. Our results demonstrate that adherence to a protocol using multiple strategies to reduce infection results in a lower SSI rate, lower care costs, and improved patient-related outcomes.

Level of Evidence

Level III.

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA, 02115, USA

    Michael Glotzbecker MD, Michael Troy BS, Patricia Miller MS, Jay Berry MD, MPH, Lara Cohen BS, Alexandra Gryzwna BA, Mary Ellen McCann MD, M. Timothy Hresko MD, Susan Goobie MD, John Emans MD, Robert Brustowitz MD, Brian Snyder MD, PhD & Daniel Hedequist MD

Authors
  1. Michael Glotzbecker MD
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  2. Michael Troy BS
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  3. Patricia Miller MS
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  4. Jay Berry MD, MPH
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  5. Lara Cohen BS
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  6. Alexandra Gryzwna BA
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  7. Mary Ellen McCann MD
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  8. M. Timothy Hresko MD
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  9. Susan Goobie MD
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  10. John Emans MD
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  11. Robert Brustowitz MD
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  12. Brian Snyder MD, PhD
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  13. Daniel Hedequist MD
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Corresponding author

Correspondence to Michael Glotzbecker MD.

Additional information

Author disclosures: MG (other from DePuy Synthes, Medtronic, Zimmer BioMet, NuVasive, and Orthobullets; other from Member of Growing Spine Study Group [GSSG], Children Spine Study Group [CSSG], The Harms Study Group [HSG], outside the submitted work), MT (none), PM (none), JB (none), MPH, LC (none), AG (none), MEM (none), MTH (nonfinancial support from Medtronics and NuVasive; personal fees from Boston Brace international, outside the submitted work; board of directors of the Pediatric Orthopaedic Society of North America [POSNA]; and committee chair, Scoliosis Research Society), SG (grants from Scoliosis Research Society; other from Octapharma, outside the submitted work), JE (personal fees from Biomet, DePuy, Medtronic Sofamor Danek, and Synthes; other from Journal of Pediatric Orthopedics, outside the submitted work), RB (none), BS (nonfinancial support from Orthopediatrics; other from American Academy of Orthopaedic Surgeons [AAOS], Orthopaedic Research Society, POSNA, and Scoliosis Research Society, outside the submitted work), DH (other from AAOS and POSNA, outside the submitted work).

IRB Approval:

No funding was received for this work from any of the following organizations: National Institutes of Health (NIH); Welcome Trust; Howard Hughes Medical Institute (HHM).

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Glotzbecker, M., Troy, M., Miller, P. et al. Implementing a Multidisciplinary Clinical Pathway Can Reduce the Deep Surgical Site Infection Rate After Posterior Spinal Fusion in High-Risk Patients. Spine Deform 7, 33–39 (2019). https://doi.org/10.1016/j.jspd.2018.06.010

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  • DOI: https://doi.org/10.1016/j.jspd.2018.06.010

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