title: A standardized protocol to reduce pediatric spine surgery infection: a quality improvement initiative.
abstract: OBJECTIVE
  Quality improvement methods are being implemented in various areas of medicine. In an effort to reduce the complex (instrumented) spine infection rate in pediatric patients, a standardized protocol was developed and implemented at an institution with a high case volume of instrumented spine fusion procedures in the pediatric age group.
  
  
  METHODS
  Members of the Texas Children's Hospital Spine Study Group developed the protocol incrementally by using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied to all children undergoing complex spine surgery starting August 21, 2012. Acute infections were defined as positive wound cultures within 12 weeks of surgery, defined in alignment with current hospital infection control criteria. Procedures and infections were measured before and after protocol implementation. This protocol received full review and approval of the Baylor College of Medicine institutional review board.
  
  
  RESULTS
  Nine spine surgeons performed 267 procedures between August 21, 2012, and September 30, 2013. The minimum follow-up was 12 weeks. The annual institutional infection rate prior to the protocol (2007-2011) ranged from 3.4% to 8.9%, with an average of 5.8%. After introducing the protocol, the infection rate decreased to 2.2% (6 infections of 267 cases) (p = 0.0362; absolute risk reduction 3.6%; relative risk 0.41 [95% CI 0.18-0.94]). Overall compliance with data form completion was 63.7%. In 4 of the 6 cases of infection, noncompliance with completion of the data collection form was documented; moreover, 2 of the 4 spine surgeons whose patients experienced infections had the lowest compliance rates in the study group.
  
  
  CONCLUSIONS
  The standardized protocol for complex spine surgery significantly reduced surgical site infection at the authors' institution. The overall compliance with entry into the protocol was good. Identification of factors associated with post-spine surgery wound infection will allow further protocol refinement in the future.
authors: Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.
authors: Sheila L
authors: SL
authors: Ryan
authors: Anish
authors: A
authors: Sen
authors: Kristen
authors: K
authors: Staggers
authors: Thomas G
authors: TG
authors: Luerssen
authors: Andrew
authors: A
authors: Jea
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols / Q000592:standards*; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D008875:Middle Aged; D009493:Neurosurgery; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000592:standards* / Q000706:statistics & numerical data; D019637:Orthopedic Procedures / Q000009:adverse effects / Q000592:standards* / Q000706:statistics & numerical data; D009985:Orthopedics; D010372:Pediatrics / Q000592:standards*; D011322:Primary Prevention / Q000379:methods / Q000592:standards; D011446:Prospective Studies; D058996:Quality Improvement; D013116:Spinal Cord / Q000601:surgery*; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control*; D013781:Texas / Q000453:epidemiology; D013997:Time Factors; D000078329:Workforce
keywords: HCRN = Hydrocephalus Clinical Research Network; SSI = surgical site infection; infection; pediatric spine; quality improvement; spinal instrumentation; spine surgery