General Session: Value and Outcomes in Spine Surgery

Presented by: D. Ou-Yang - View Audio/Video Presentation (Members Only)


E. Burger(1), M. Sandoval(2), D. Ou-Yang(3)

(1) University of Colorado - Denver, Orthopedics, Aurora, CO, United States
(2) University of Colorado - Denver, Aurora, CO, United States
(3) University of Colorado Anschutz Medical Campus, Department of Orthopedics, Aurora, CO, United States


Surgical site infections (SSIs) are the most prevalent and costly health care acquired condition (HAI). The estimated cost of a surgical site infection ranges between USD$18,500 and $28,000. The cost does not include indirect costs such as missed work days or negative impact on a patient or care taker's quality of life. “Bundles of care,” comprised of standard, evidence-based interventions have been identified as an effective strategies to reduce SSIs.

Purpose: The aims of this quality improvement project were multifold. The aims were to: 1.) Identify standard, evidence-based elements for a spine SSI bundle;
2.) Identify outcome measures to evaluate the effectiveness of the bundle; and,
3.) Develop a standardized scorecard to evaluate the bundle effectiveness in increasing patient compliance with evidence-based elements of the bundle and reducing SSIs.

Methods: A multidisciplinary task force was formed to identify and implement interventions after an extensive review of the literature was conducted and best practices were identified. Elements of a spine SSI-bundle were identified and a spine bundle was formed. The bundle included replacement of the standard of care of nasal staph aureus decolonization (mupirocin ointment, 3-5 days preoperatively) with a novel approach that included nasal application of povidone-iodine by a nurse during the preoperative phase. Additional elements included in the bundle were: 1.) Outpatient showers x3 consecutive days with antimicrobial solution;
2.) Application of a chlorhexidine gluconate wipe to surgical site prior to surgery in preoperative phase;
3.) Hair removal with a clipper, only if necessary; and,
4.) Intraoperative skin preparation using iodine povacrylex/isopropyl alcohol.

A gap analysis was performed and areas for improvement were identified, including: Standardization of order sets, preference cards, and provider and patient education with bundle elements. Plan-Do-Study-Act (PDSA) quality improvement method was used to evaluate the process of change.

Findings: Overall, the spine SSI bundle was effective in reducing infections. Compliance varied, and was affected by periodic staff education. The element of the bundle most problematic was preoperative showering. SSIs and patient compliance were evaluated quarterly. In quarter 3 of 2015, an increase in infections occurred among spine patients. In collaboration with infection prevention specialists, spine patients who had experienced SSIs were patients admitted to surgery from inpatient units and were not recipients of the bundle. The replacement of mupirocin ointment ordered for outpatient use with nasal povidone-iodine eliminated the reliability of self-reported compliance for nasal staph decolonization.

Conclusions: Modified bundles to reduce SSIs in surgical spine patients should be considered for emergent, urgent, or nonscheduled cases, to ensure that each patient receives interventions aimed to reduce SSIs.
Evidence-based bundles should be identified and implemented to reduce infection rates, minimize variance in practice, enhance efficiency, and reduce cost in healthcare.

SSI Bundle Outcomes