A standardized protocol to reduce pediatric spine surgery infection: a quality improvement initiative

Clinical article

Full access

Object

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.

Abbreviations used in this paper:HCRN = Hydrocephalus Clinical Research Network; SSI = surgical site infection.

Abstract

Object

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.

Perioperative surgical site infections (SSIs) after pediatric spine fusion are well-described complications with rates ranging from 0.5% to 1.6% in idiopathic scoliosis to 3.7% to 8.5% in combined idiopathic and nonidiopathic scoliosis series.4,12,14–16,21 Some patient cohorts are at an increased risk for SSIs after spinal fusion; SSI rates for patients with spinal dysraphism range from 8% to 41.7%, and for those with cerebral palsy range from 6.1% to 15.2%.1,2,6,9,17,19,20 Surgical site infections impart a tremendous burden on the health and well-being of patients and their families and bear a significant cost to the health care system8 and to the individual health care provider as future reimbursement practices in the US health care system incorporate pay-for-performance measures and attempt to link patient outcomes to provider payments.

Considerable variation exists in infection prevention practices for spine surgery by the center and by the surgeon.21 This variation most likely reflects differences in training and expertise and gaps in the available evidence regarding various potential approaches.

Recent work in other areas of medicine and surgery has demonstrated beneficial results from quality improvement methodology.13 This methodology involves the development and implementation of standardized, incremental protocols for common health care processes to decrease unexplained clinical variation, measurement of compliance, and observation of the effect on outcome.13 The Hydrocephalus Clinical Research Network (HCRN) in pediatric neurosurgery demonstrated a decreased CSF shunt infection rate from 8.8% prior to application of a standardized protocol to 5.7% while using the protocol.13

Our goal was to apply these quality improvement methodologies to complex spine surgery in children in an effort to reduce the 12-week acute infection rate.

Methods

Study Setting

The Texas Children's Hospital Spine Study Group is a collaboration of pediatric neurosurgeons and pediatric orthopedic surgeons conducting systematic investigations in the management and treatment of pediatric spinal disorders. In an effort to reduce the risk of postoperative wound infections after instrumented spine fusions, members of this study group adopted a quality improvement methodology. Prior to implementation of this standardized protocol, individual surgeons used a variety of perioperative techniques to try to prevent infection; there was substantial variation from one surgeon to another. The study group agreed to develop a standardized multistep protocol to try to reduce the infection rate across our institution.

Quality Improvement Protocol Development and Implementation

The protocol was developed by Texas Children's Hospital Spine Study Group members using the current literature7,21 and prior institutional experience (Fig. 1). The protocol steps were discussed during bimonthly meetings. The details were revised until consensus was obtained. The protocol was reviewed by representatives from the Texas Children's Hospital Infection Control Service, Department of Pharmacy, and the neurosurgical and orthopedic operating rooms. The protocol was instituted with the approval of the institutional review board and the Department of Surgery Office of Quality and Patient Safety, and the data were collected locally.

Fig. 1.
Fig. 1.

Diagram showing the Texas Children's Hospital spine surgery protocol. Note: A Betadine soak is defined by Cheng et al.5 as: soaking the surgical wound with dilute povidone-iodine solution for 3 minutes using commercially available Betadine solution that has a concentration of 10% povidone-iodine (100 mg of povidone-iodine per 1 ml of solution). The wound is then irrigated with normal saline (2000 ml) after the Betadine solution irrigation. BMP = bone morphogenetic protein; EBL = estimated blood loss; MRN = medical record number; PRN = when necessary.

Entry Criteria

All children at our institution were entered into the study when they underwent spine fusion with instrumentation or revision surgery with instrumentation in place. Patients whose first presentation was with wound infection were entered into the study after their infections were treated.

Procedures were classified as initial or revision surgery. Patient diagnoses were grouped as idiopathic, congenital, or neuromuscular spinal deformity, or degenerative spine disease, tumor, or trauma. Other operative data, such as region of the spine where surgery was performed, length of surgery, type of bone graft, estimated blood loss, and number of people in the operating room, were recorded. All repeated procedures of any type were recorded.

Outcome Variable

Patients were evaluated for infection at the time of routine clinical follow-up, emergency room visits, or hospital admission. Evaluation followed the surgeon's usual clinical practice. The primary end point for the study was the Scoliosis Research Society definition of acute infection: positive wound cultures within 12 weeks of surgery.3

Data Collection

For protocol compliance, a flow sheet outlining the steps was used for data collection (Fig. 1). The surgeon or designated member of the operative team was responsible for completing the data collection form. A full-time research coordinator collected the data prospectively and entered them into our database. Compliance with each step was recorded.

Data Analysis

Data were stored locally and then aggregated for this analysis. Data on infection rates after instrumented spine fusion prior to application of the protocol were obtained from hospital infection control records (Fig. 2).

Fig. 2.
Fig. 2.

Histogram demonstrating the historical surgical site infection rates for complex spine surgery at Texas Children's Hospital from 2007 to 2011. FY = fiscal year.

Statistical analysis was performed using commercially available software (SPSS version 17.0, SAS version 9.2); p values were computed using the standard 2-tailed Fisher exact test. Control charts were created with QI Charts (version 2.0), an add-in for Microsoft Excel.

Results

Nine surgeons as part of the Texas Children's Hospital Spine Service performed 267 instrumented spine fusions using the protocol from August 21, 2012, to September 30, 2013. For this analysis, follow-up monitoring closed on December 31, 2013, following the 12-week period for acute infection. One hundred sixty-eight (62.9%) of the 267 data collection forms were available for analysis. The monthly compliance for completion of the data collection form ranged from 38% to 89% (mean 63.7%) (Fig. 3). Compliance with protocol steps is outlined in Table 1.

Fig. 3.
Fig. 3.

Bar chart comparing the number of procedures and the compliance with data form completions per month.

TABLE 1:

Individual components of the protocol*

Protocol ProcedureCompliance
sign on OR door96%
ensure preincision antibiotics98%
redosing of antibiotics65%
clip hair PRN61%
dirt, debris, & adhesive material removed85%
ChloraPrep applied & not washed off98%
wait 3 minutes99%
Avagard hand scrub95%
double gloves92%
Ioban surgical drape98%
irrigate w/ Bacitracin76%
change outer gloves85%
vancomycin powder sprinkled into surgical bed91%
drain placement70%
antibiotic-impregnated sutures57%
dressing77%
“mud flap” PRN4%
postop orders of same antibiotic82%
Betadine soak33%

OR = operating room; PRN = when necessary.

A Betadine soak is defined by Cheng et al.5 as: soaking the surgical wound with dilute povidone-iodine solution for 3 minutes using commercially available Betadine solution that has a concentration of 10% povidoneiodine (100 mg of povidone-iodine per 1 ml of solution). The wound is then irrigated with normal saline (2000 ml) after the Betadine solution irrigation.

One hundred sixty-eight procedures were performed in 162 children. The mean age at surgery was 13.8 years and 5.7 months (range 1 year and 11 months to 23 years and 1 month). The most common procedure type was initial spine fusion (78.4%) followed by revision surgery (21.6%). Diagnoses at the time of surgery included idiopathic (39.8%), congenital (21.9%), and neuromuscular spinal deformities (18.0%), followed by degenerative processes (2.3%), trauma (15.6%), and tumor (2.4%). Surgery was performed on the cervical spine (21.7% of cases), thoracic spine (18.3%), lumbar spine (7.5%), cervical and thoracic spine (1.3%), thoracic and lumbar spine (34.7%), lumbar and sacral spine (4.7%), thoracic spine to pelvis (10.9%), and lumbar spine to pelvis (0.6%). The length of surgery was less than 2 hours (8.4%), 2–4 hours (52.4%), 4–6 hours (21.7%), 6–8 hours (15.3%), and longer than 8 hours (2%). Allograft alone was used in 19.5% of cases. Autograft alone was used in 8.3% of cases. A combination of allograft and autograft was used in 72.2% of cases. Bone morphogenetic protein was used in 35.3% of cases. The mean estimated blood loss was 475.2 ml (range 5–2700 ml).

The total number of personnel in the operating room at the time of surgery ranged from 5 to 29 people (mean 12 people). Infection occurred after 6 (2.2%) of the 267 procedures (Fig. 4, Table 2); data collection forms were not completed in 4 of these 6 cases of infection.

Fig. 4.
Fig. 4.

T-chart showing the number of days between infections overall.

TABLE 2:

Spine infection rate by month

MonthInfectionsNo. of ProceduresRate
August 20121812.5%
September 2012090%
October 20120150%
November 20120150%
December 20120220%
January 20130230%
February 20130120%
March 20131911.11%
April 20130210%
May 20131166.25%
June 20130400%
July 20130410%
August 20132258.0%
September 20131119.10%
overall62672.2%

Each surgeon performed between 1 and 87 procedures. Surgeon-specific infection rates varied (0%–9.38%) and did not appear to correlate with surgeon procedure volume (Table 3). However, it is interesting to note that 2 of the 4 surgeons whose patients experienced infection had the lowest compliance rates of data form completion in our study group.

TABLE 3:

Spine infection rate by individual surgeon*

SurgeonNo. of ProceduresInfection RateData Form Completion Rate
A329.38%34.4%
B220%54.5%
C871.15%48.3%
D20%50%
E721.39%100%
F10%0%
G110%81.8%
H230%60.9%
I175.88%52.9%
overall2672.2%63.7%

Two of the 4 surgeons who experienced infection completed the data collection form less than 50% of the time.

The institution-wide infection rate while the protocol was in place (2.2%) was significantly lower (p = 0.0362) than the preprotocol infection rate of 3.4%–8.9%. This represents an absolute risk reduction of 3.6% and a relative risk reduction of 59%.

Case Study

Preprotocol and postprotocol data were available for Surgeon E. Surgeon E experienced 7 cases of infections in 6 different patients in his first 107 instrumented spine fusions (6.5%), from September 1, 2007, to August 20, 2012 (6.5%). After the protocol was implemented, Surgeon E experienced 1 infection in his last 72 cases (1.4%), from August 21, 2012, to September 30, 2013 (pre- vs postprotocol infection rate p = 0.21; relative risk 0.21 [95% CI 0.023–1.69]). Figure 5 demonstrates a T-chart—days between infections—for Surgeon E before and after utilizing the standardized protocol.

Fig. 5.
Fig. 5.

T-chart showing the number of days between infections for Surgeon E.

Discussion

Surgical site infections are complications of instrumented spine fusion procedures in pediatric patients. These infections impose a heavy burden on the health and well-being of affected children and their families. Financial costs of SSIs are also substantial, and estimates range from $26,977 to $961,722 due to hospital readmissions and repeat surgeries.11 Therefore, there is an increasing interest in decreasing SSI rates in pediatric spine surgery through the implementation of quality improvement strategies.

As in so many areas of clinical medicine, available literature in this area lacks the methodological rigor to alone support a practical and useful clinical practice guideline.22 N onetheless, s ignificant d ocumented u nexplained variation in current clinical practice in the approach to SSIs after instrumented spine fusion procedures in pediatric patients demands due attention.7

Within our institution, application of a standardized protocol for 267 instrumented spine fusion procedures in the pediatric age group reduced the infection rate from 3.4%–8.9% to 2.2% (p = 0.0362). These infection rates both before and after institution of the protocol are similar to those reported in the literature.

The overall compliance of 63.7% compares favorably with other multistep protocols. In the WHO surgical checklist study,10 compliance with 6 of 19 steps was recorded and full compliance occurred in 34.2% of patients at baseline and rose to 56.7% after implementation of the protocol. Higher rates of compliance (82% and 84%, respectively) were noted in the National Association of Children's Hospitals and Related Institutions (NACHRI) study of central line infections18 and the HCRN study on shunt infections (74.5%).13 Future directions for our quality improvement project include a plan to refine the protocol to the smallest number of steps that appear to have an impact on infection; a shorter, more straightforward protocol is more likely to have higher compliance.

Limitations

The small absolute number of infections in our series during the study period precluded logistic regression analysis or other statistical methods to identify risk factors. In 4 of the 6 infections, data collection forms were not completed; moreover, 2 of the 4 surgeons associated with postoperative wound infections had the lowest compliance rates in our study group. While it is tempting to conclude that compliance rate is inversely related to infection rate, we are unable to show this with meaningful statistical significance (Fig. 6).

Fig. 6.
Fig. 6.

Scatter plot and linear regression comparing data form completion rate (x axis) with infection rates (y axis) among surgeons.

Conclusions

The implementation of a standardized protocol for the prevention of SSIs after instrumented spine fusion procedures in children has had a number of advantages. We have reduced our institution-wide infection rate to 2.2%, sustained over a 13-month period. The protocol has established a common baseline at our institution that will facilitate assessment of new treatments in the future. We now have institution-specific data that will allow us to establish a “standard of care” and to identify outliers. It is not clear whether any of the specific steps within the protocol have been instrumental in reducing infection rate, or if it is the implementation of a standardized protocol decreasing unexplained clinical variation that has decreased infection rate. Simply providing surgeons with their own data may improve protocol adherence and further reduce infection rates. Observation of surgeons with very low infection rates may allow us to identify protocol and nonprotocol factors that could be added to the protocol in the near future.

Acknowledgment

The Texas Children's Hospital Spine Study Group consists of the following personnel: David P. Antekeier, M.D.; Shannon B. Antekier, M.D.; Kathleen E. Carberry, R.N.; Howard R. Epps, M.D.; Frank T. Gerow, M.D.; Darrell S. Hanson, M.D.; Kevin S. Horowitz, M.D.; Andrew Jea, M.D.; Kenneth L. Kocab, R.N.; Scott D. McKay, M.D.; William A. Phillips, M.D.; Scott Rosenfeld, M.D.; and Sheila L. Ryan, M.P.H., J.D.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Jea. Acquisition of data: Jea, Ryan, Staggers. Analysis and interpretation of data: Jea, Ryan, Staggers. Drafting the article: Jea. Critically revising the article: Jea, Ryan, Sen. Reviewed submitted version of manuscript: Jea, Ryan. Approved the final version of the manuscript on behalf of all authors: Jea. Study supervision: Luerssen.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

References

  • 1

    Banit DMIwinski HJ JrTalwalkar VJohnson M: Posterior spinal fusion in paralytic scoliosis and myelomeningocele. J Pediatr Orthop 21:1171252001

  • 2

    Benson ERThomson JDSmith BGBanta JV: Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular scoliosis. Spine (Phila Pa 1976) 23:230823181998

  • 3

    Broadstone P: 2012 – Morbidity and Mortality On-line Reporting. Scoliosis Research Society (http://www.srs.org/mmreport/2012%20How%20to%20Submit%2012.2011%20v2.pdf) [Accessed May 29 2014]

  • 4

    Cahill PJWarnick DELee MJGaughan JVogel LEHammerberg KW: Infection after spinal fusion for pediatric spinal deformity: thirty years of experience at a single institution. Spine (Phila Pa 1976) 35:121112172010

  • 5

    Cheng MTChang MCWang STYu WKLiu CLChen TH: Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine (Phila Pa 1976) 30:168916932005

  • 6

    Geiger FParsch DCarstens C: Complications of scoliosis surgery in children with myelomeningocele. Eur Spine J 8:22261999

  • 7

    Glotzbecker MPRiedel MDVitale MGMatsumoto HRoye DPErickson M: What's the evidence? Systematic literature review of risk factors and preventive strategies for surgical site infection following pediatric spine surgery. J Pediatr Orthop 33:4794872013

  • 8

    Harrod CCBoykin REHedequist DJ: Complications of infection in pediatric spine surgery. Pediatr Health 3:5795922009

  • 9

    Hatlen TSong KShurtleff DDuguay S: Contributory factors to postoperative spinal fusion complications for children with myelomeningocele. Spine (Phila Pa 1976) 35:129412992010

  • 10

    Haynes ABWeiser TGBerry WRLipsitz SRBreizat AHDellinger EP: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:4914992009

  • 11

    Hedequist DHaugen AHresko TEmans J: Failure of attempted implant retention in spinal deformity delayed surgical site infections. Spine (Phila Pa 1976) 34:60642009

  • 12

    Ho CSkaggs DLWeiss JMTolo VT: Management of infection after instrumented posterior spine fusion in pediatric scoliosis. Spine (Phila Pa 1976) 32:273927442007

  • 13

    Kestle JRRiva-Cambrin JWellons JC IIIKulkarni AVWhitehead WEWalker ML: A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. Clinical article. J Neurosurg Pediatr 8:22292011

  • 14

    Labbé ACDemers AMRodrigues RArlet VTanguay KMoore DL: Surgical-site infection following spinal fusion: a case-control study in a children's hospital. Infect Control Hosp Epidemiol 24:5915952003

  • 15

    Linam WMMargolis PAStaat MABritto MTHornung RCassedy A: Risk factors associated with surgical site infection after pediatric posterior spinal fusion procedure. Infect Control Hosp Epidemiol 30:1091162009

  • 16

    Mackenzie WGMatsumoto HWilliams BACorona JLee CCody SR: Surgical site infection following spinal instrumentation for scoliosis: a multicenter analysis of rates, risk factors, and pathogens. J Bone Joint Surg Am 95:800806S1S22013

  • 17

    McMaster MJ: Anterior and posterior instrumentation and fusion of thoracolumbar scoliosis due to myelomeningocele. J Bone Joint Surg Br 69:20251987

  • 18

    Miller MRGriswold MHarris JM IIYenokyan GHuskins WCMoss M: Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts. Pediatrics 125:2062132010

  • 19

    Osebold WRMayfield JKWinter RBMoe JH: Surgical treatment of paralytic scoliosis associated with myelomeningocele. J Bone Joint Surg Am 64:8418561982

  • 20

    Stella GAscani ECervellati SBettini NScarsi MVicini M: Surgical treatment of scoliosis associated with myelomeningocele. Eur J Pediatr Surg 8:Suppl 122251998

  • 21

    Vitale MGRiedel MDGlotzbecker MPMatsumoto HRoye DPAkbarnia BA: Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop 33:4714782013

  • 22

    Wright JGSwiontkowski MFHeckman JD: Introducing levels of evidence to the journal. J Bone Joint Surg Am 85-A:132003

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Address correspondence to: Andrew Jea, M.D., Neuro-Spine Program, Texas Children's Hospital, CCC 1230.01, 12th Floor, Houston, TX 77030. email: ahjea@texaschildrens.org.

Please include this information when citing this paper: published online June 27, 2014; DOI: 10.3171/2014.5.PEDS1448.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Diagram showing the Texas Children's Hospital spine surgery protocol. Note: A Betadine soak is defined by Cheng et al.5 as: soaking the surgical wound with dilute povidone-iodine solution for 3 minutes using commercially available Betadine solution that has a concentration of 10% povidone-iodine (100 mg of povidone-iodine per 1 ml of solution). The wound is then irrigated with normal saline (2000 ml) after the Betadine solution irrigation. BMP = bone morphogenetic protein; EBL = estimated blood loss; MRN = medical record number; PRN = when necessary.

  • View in gallery

    Histogram demonstrating the historical surgical site infection rates for complex spine surgery at Texas Children's Hospital from 2007 to 2011. FY = fiscal year.

  • View in gallery

    Bar chart comparing the number of procedures and the compliance with data form completions per month.

  • View in gallery

    T-chart showing the number of days between infections overall.

  • View in gallery

    T-chart showing the number of days between infections for Surgeon E.

  • View in gallery

    Scatter plot and linear regression comparing data form completion rate (x axis) with infection rates (y axis) among surgeons.

References

1

Banit DMIwinski HJ JrTalwalkar VJohnson M: Posterior spinal fusion in paralytic scoliosis and myelomeningocele. J Pediatr Orthop 21:1171252001

2

Benson ERThomson JDSmith BGBanta JV: Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular scoliosis. Spine (Phila Pa 1976) 23:230823181998

3

Broadstone P: 2012 – Morbidity and Mortality On-line Reporting. Scoliosis Research Society (http://www.srs.org/mmreport/2012%20How%20to%20Submit%2012.2011%20v2.pdf) [Accessed May 29 2014]

4

Cahill PJWarnick DELee MJGaughan JVogel LEHammerberg KW: Infection after spinal fusion for pediatric spinal deformity: thirty years of experience at a single institution. Spine (Phila Pa 1976) 35:121112172010

5

Cheng MTChang MCWang STYu WKLiu CLChen TH: Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine (Phila Pa 1976) 30:168916932005

6

Geiger FParsch DCarstens C: Complications of scoliosis surgery in children with myelomeningocele. Eur Spine J 8:22261999

7

Glotzbecker MPRiedel MDVitale MGMatsumoto HRoye DPErickson M: What's the evidence? Systematic literature review of risk factors and preventive strategies for surgical site infection following pediatric spine surgery. J Pediatr Orthop 33:4794872013

8

Harrod CCBoykin REHedequist DJ: Complications of infection in pediatric spine surgery. Pediatr Health 3:5795922009

9

Hatlen TSong KShurtleff DDuguay S: Contributory factors to postoperative spinal fusion complications for children with myelomeningocele. Spine (Phila Pa 1976) 35:129412992010

10

Haynes ABWeiser TGBerry WRLipsitz SRBreizat AHDellinger EP: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:4914992009

11

Hedequist DHaugen AHresko TEmans J: Failure of attempted implant retention in spinal deformity delayed surgical site infections. Spine (Phila Pa 1976) 34:60642009

12

Ho CSkaggs DLWeiss JMTolo VT: Management of infection after instrumented posterior spine fusion in pediatric scoliosis. Spine (Phila Pa 1976) 32:273927442007

13

Kestle JRRiva-Cambrin JWellons JC IIIKulkarni AVWhitehead WEWalker ML: A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. Clinical article. J Neurosurg Pediatr 8:22292011

14

Labbé ACDemers AMRodrigues RArlet VTanguay KMoore DL: Surgical-site infection following spinal fusion: a case-control study in a children's hospital. Infect Control Hosp Epidemiol 24:5915952003

15

Linam WMMargolis PAStaat MABritto MTHornung RCassedy A: Risk factors associated with surgical site infection after pediatric posterior spinal fusion procedure. Infect Control Hosp Epidemiol 30:1091162009

16

Mackenzie WGMatsumoto HWilliams BACorona JLee CCody SR: Surgical site infection following spinal instrumentation for scoliosis: a multicenter analysis of rates, risk factors, and pathogens. J Bone Joint Surg Am 95:800806S1S22013

17

McMaster MJ: Anterior and posterior instrumentation and fusion of thoracolumbar scoliosis due to myelomeningocele. J Bone Joint Surg Br 69:20251987

18

Miller MRGriswold MHarris JM IIYenokyan GHuskins WCMoss M: Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts. Pediatrics 125:2062132010

19

Osebold WRMayfield JKWinter RBMoe JH: Surgical treatment of paralytic scoliosis associated with myelomeningocele. J Bone Joint Surg Am 64:8418561982

20

Stella GAscani ECervellati SBettini NScarsi MVicini M: Surgical treatment of scoliosis associated with myelomeningocele. Eur J Pediatr Surg 8:Suppl 122251998

21

Vitale MGRiedel MDGlotzbecker MPMatsumoto HRoye DPAkbarnia BA: Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop 33:4714782013

22

Wright JGSwiontkowski MFHeckman JD: Introducing levels of evidence to the journal. J Bone Joint Surg Am 85-A:132003

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 213 213 53
PDF Downloads 197 197 28
EPUB Downloads 0 0 0

PubMed

Google Scholar