Standardizing preoperative preparation to reduce surgical site infections among pediatric neurosurgical patients

Joshua K. Schaffzin Division of Infectious Diseases,

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Katherine Simon James M. Anderson Center for Health Systems Excellence, and

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Beverly L. Connelly Division of Infectious Diseases,

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Francesco T. Mangano Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

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OBJECTIVE

Surgical site infections (SSIs) are costly to patients and the health care system. Pediatric neurosurgery SSI risk factors are not well defined. Intraoperative protocols have reduced, but have not eliminated, SSIs. The effect of preoperative intervention is unknown. Using quality improvement methods, a preoperative SSI prevention protocol for pediatric neurosurgical patients was implemented to assess its effect on SSI rate.

METHODS

Patients who underwent a scheduled neurosurgical procedure between January 2014 and December 2015 were included. Published evidence and provider consensus were used to guide preoperative protocol development. The Model for Improvement was used to test interventions. Intraoperative and postoperative management was not standardized or modified systematically. Staff, family, and overall adherence was measured as all-or-nothing. In addition, SSI rates among eligible procedures were measured before and after protocol implementation.

RESULTS

Within 4 months, overall protocol adherence increased from 51.3% to a sustained 85.7%. SSI rates decreased from 2.9 per 100 procedures preintervention to 0.62 infections postintervention (p = 0.003). An approximate 79% reduction in SSI risk was identified (risk ratio 0.21, 95% CI 0.08–0.56; p = 0.001).

CONCLUSIONS

Clinical staff and families successfully collaborated on a standardized preoperative protocol for pediatric neurosurgical patients. Standardization of the preoperative phase of care alone reduced SSI rates. Attention to the preoperative in addition to the intraoperative and postoperative phases of care may lead to further reduction in SSI rates.

ABBREVIATIONS

CHG = chlorhexidine gluconate; SSI = surgical site infection.

OBJECTIVE

Surgical site infections (SSIs) are costly to patients and the health care system. Pediatric neurosurgery SSI risk factors are not well defined. Intraoperative protocols have reduced, but have not eliminated, SSIs. The effect of preoperative intervention is unknown. Using quality improvement methods, a preoperative SSI prevention protocol for pediatric neurosurgical patients was implemented to assess its effect on SSI rate.

METHODS

Patients who underwent a scheduled neurosurgical procedure between January 2014 and December 2015 were included. Published evidence and provider consensus were used to guide preoperative protocol development. The Model for Improvement was used to test interventions. Intraoperative and postoperative management was not standardized or modified systematically. Staff, family, and overall adherence was measured as all-or-nothing. In addition, SSI rates among eligible procedures were measured before and after protocol implementation.

RESULTS

Within 4 months, overall protocol adherence increased from 51.3% to a sustained 85.7%. SSI rates decreased from 2.9 per 100 procedures preintervention to 0.62 infections postintervention (p = 0.003). An approximate 79% reduction in SSI risk was identified (risk ratio 0.21, 95% CI 0.08–0.56; p = 0.001).

CONCLUSIONS

Clinical staff and families successfully collaborated on a standardized preoperative protocol for pediatric neurosurgical patients. Standardization of the preoperative phase of care alone reduced SSI rates. Attention to the preoperative in addition to the intraoperative and postoperative phases of care may lead to further reduction in SSI rates.

Surgical site infections (SSIs) are common health care–associated infections that increase patient morbidity and mortality rates and cost the US health care system billions of dollars annually.32,53 Neurosurgical SSIs in pediatric patients are particularly devastating.12,58 Published risk factors for SSIs following pediatric neurosurgical procedures have focused predominantly on ventricular shunt procedures and have identified a variety of factors that affect the occurrence of SSIs.1,23,51,54,56,61 Similarly, numerous risk factors for SSIs in adults following neurosurgery have been identified.10,55,59 However, the identification of key factors that can prevent SSIs has been elusive. Numerous protocols have been published, and in the absence of a national consensus, current practice is probably institution specific, derived from experience and available evidence.23,30,36 The Centers for Disease Control and Prevention SSI prevention guidelines define a care continuum for all surgical patients including preoperative evaluation, day of surgery preparation, the procedure itself, and postoperative care (hospital and home).39 Despite the importance of preoperative attention, our center has not implemented standardized preoperative interventions systematically.

We developed an SSI prevention protocol to address preoperative patient risk factors. Our goal was to standardize practice and to engage families directly in the SSI prevention process. Standardization and family engagement have been shown to improve care among orthopedic surgery patients.5,13 We hypothesized that standardization of practice and direct family involvement in the preoperative phase of care would generate high protocol adherence and prevent SSIs in our pediatric neurosurgical population.

Methods

Setting and Population

Cincinnati Children's Hospital Medical Center is a 523-bed academic, freestanding children's hospital. At any point during the study period, the neurosurgical service had up to 4 surgeons who performed approximately 750 routine and complex procedures during calendar year 2014.

Preintervention Care Coordination

A standard intraoperative bundle was implemented in 2009 that recommended preoperative bathing. Surgical candidates were provided with a bottle of baby shampoo when seen in the clinic and were instructed to bathe the night before and the morning of surgery. Adherence to this provision or recommendation was not tracked. The remainder of the bundle included wiping the patient at the anticipated incision site(s) with a chlorhexidine gluconate (CHG)–impregnated cloth prior to operating room transfer, proper intraoperative antibiotic timing, and maintenance of the patient's oxygenation and body temperature.50 Additionally, many postoperative patients were instructed to cleanse the surgical incision daily with soap and water; this practice was not standardized among all patients or surgeons, and adherence was not tracked.

Inclusion/Exclusion Criteria and Operational Definitions

All patients undergoing elective neurosurgery (defined as surgery planned in advance through the outpatient clinic) between January 1, 2014, and December 31, 2015, were eligible for inclusion. Patients undergoing cerebral angiography, surgery for acute trauma, emergent adverse events (e.g., infection, shunt revision, and so on), and those scheduled for a procedure as inpatients were excluded. Suspected postoperative infections were identified and reviewed by the hospital's infection control program. SSIs were defined using National Healthcare Safety Network definitions and were counted by procedure date.8 For pre- and postimplementation comparisons, procedures were placed in 1 of the following categories: craniotomy (craniotomy for epilepsy, tumor, third ventriculostomy, posterior fossa decompression, and invasive craniofacial procedure); shunt (any procedure for which the purpose was to place or modify a shunt or extraventricular drain); vascular (craniotomy for arteriovenous malformation resection or revascularization following moyamoya); implant (placement, revision, or removal of vagal nerve stimulator, intrathecal baclofen pump, or deep brain stimulator); spine (laminectomy, tethered cord release, dorsal rhizotomy, or spinal fusion); and other (dermoid cyst excision or noninvasive craniofacial procedure). This quality improvement initiative was submitted and considered exempt from formal review by the Cincinnati Children's Hospital Medical Center IRB.

Protocol Development

A multidisciplinary improvement team was created to apply the model for improvement method to develop and implement a preoperative SSI prevention protocol.35 The team discussed existing practice, published evidence, and provider preference to determine the 5 protocol components assigned to 3 groups of stakeholders: neurosurgery clinic nurses, patients/families, and preoperative unit nurses (Table 1).

TABLE 1.

Preoperative protocol components

ComponentStakeholderTaskBasis for Inclusion
Skin integrity assessmentClinic nurseNurse screens for acne, eczema, & other potential barriers to proper healing. Nurse refers patient for further assessment based on results.Acute wound healing is enhanced by removing barriers to proper healing, including low-pathogenicity organisms such as S. epidermidis & Propionibacterium acnes.11,20,49
FamilyPatient follows recommended actions to mitigate identified barriers.
S. aureus screening/decolonizationClinic nursePatient is screened in 2 body sites for both MSSA & MRSA.Patients known to have S. aureus colonization preop have an increased risk of SSI.33 Decolonization protocols targeting S. aureus have been shown to reduce S. aureus SSIs among adult patients undergoing hip & knee replacement procedures.4,31,44,47
FamilyPatient who has MRSA or MSSA colonization undergoes a decolonization protocol.
CHG bathsClinic nurseNurse provides family w/baby shampoo, 2% CHG solution, & written instructions for bathing.Multiple baths or showers w/CHG can reduce organisms present on the patient's skin.7,25,43
FamilyPatient is bathed w/shampoo &/or 2% CHG the night before & the morning of surgery.
CHG wipesPreop nurseNurse wipes patient's anticipated surgical site(s) w/2% CHG wipe.See above.
Patient warmerPreop nurseNurse places a forced-air warming blanket on patient & documents temperature prior to transfer to operating room.Hypothermia is a risk factor for SSI.34,40

MRSA = methicillin-resistant S. aureus; MSSA = methicillin-sensitive S. aureus.

Adherence Measurement

Adherence measurements were made according to the stakeholder responsible for component completion. There were 3 neurosurgery clinic nurse measures, up to 3 patient/family measures, and 2 preoperative unit nurse measures. The number of patient/family measures varied depending on skin integrity and Staphylococcus aureus screening results. In addition to bathing, families were expected to mitigate skin issues and/or undergo S. aureus decolonization only if skin issues and/or colonization were identified.

Intraphase Communication

Prior to this project, we observed that information gathered and actions prescribed by the clinic nurses did not reach the preoperative nurses reliably. Additionally, preoperative activities were not tracked in a standard fashion, such that it was unclear whether practices were being followed and by what percentage of patients. To streamline the information shared and to produce analyzable data, a tracking document was developed to compile all adherence data sequentially from each of the stakeholder groups. Clinic nurses completed documentation of the measures for which they were responsible (Table 1). On Friday, the forms were scanned and emailed to the preoperative area for patients who were scheduled for surgery the following week. Preoperative nurses documented adherence to the remainder of the measures through patient and family questioning and self-report.

Patient/Family Reminders

Initial failure analysis revealed that patient bathing was the most common failure. We hypothesized that reminders provided through printed materials and telephone conversations would improve patient/family bath adherence. We modified the protocol to include reminders at 3 different time points: 1) At approximately 3 months postimplementation, we added a telephone call by neurosurgery staff to patients/families when the date of surgery was set (preoperative telephone call); 2) at approximately 4 months postimplementation, we revised our printed bathing instructions for clarity and to target individual patients based on age and S. aureus colonization status; and 3) at approximately 5 months postimplementation, we added an additional telephone call when S. aureus screening results were available (S. aureus result telephone call).

Statistical Analysis

Adherence data were collected prospectively and managed using REDCap electronic data capture tools hosted by the University of Cincinnati Center for Clinical and Translational Science and Training.22 Each protocol component was counted as a success if completed and as a failure if not completed. If all data for a patient were missing from a given stakeholder (clinic nurse, patient/family, preoperative nurse), that patient was excluded from adherence calculations for that phase. Process all-or-nothing measures included protocol adherence for clinic nurses, families, preoperative nurses, and overall (all measures combined). Process data were validated prior to adherence calculations by manual review of any identified failure. Run charts were generated using SAS 9.3 (SAS Institute) for each phase to assess the effect of interventions over time.

Data were analyzed for all eligible patients per 2-week period. Preliminary median rates for each stakeholder group were established based on the first 8 points on the chart. Special cause (a pattern of performance that was not part of the existing system as a result of a change in the system) analysis was used to identify a statistically significant change in adherence rate, defined as ≥ 8 consecutive points greater than or less than the median.46 We sought to achieve 90% protocol adherence for staff, families, and overall. This goal was set based on an expectation of 10−1 performance (≤ 10 errors per 100 opportunities), which we believed would be sufficient to affect the SSI rate.35

For pre- and postimplementation comparisons, we derived two cohorts who met inclusion criteria from our institution's surgical database. To examine cohort differences by demographic data, procedure type, and surgeon, we used 2-tailed t-test and chi-square calculations. To examine differences in SSI by procedure type and surgeon, we used chi-square tests to compare the proportion of procedures performed that resulted in SSIs in each period. For the SSI rate comparison, we calculated a Pearson chi-square value and risk ratio to compare preimplementation (January 1, 2012, to December 31, 2013) and postimplementation (January 1, 2014, to December 31, 2015) rates using SAS 9.3. Fisher's exact test was used to calculate p values, with p < 0.05 considered statistically significant.

Results

Protocol Adherence

Adherence data were available for 683 of the estimated 801 eligible procedures (85.3%). The preliminary median protocol adherence for clinic nurses was 92.9% and improved to 100% in January 2015; clinic nurse adherence for the 24-month period was 95.9% (data not shown). The median protocol adherence for preoperative nurses was sustained at approximately 100% throughout the study period; preoperative nurse adherence for the 24-month period was 94.8% (data not shown). The preliminary median protocol adherence for patients/families was 83.8% and improved to 100% in March 2014 following introduction of the preoperative telephone call. The process showed a high degree of variability and shifted to 85.7% in February 2015; family adherence for the 24-month period was 89.5% (data not shown). Combining measurements from all 3 phases yielded an overall preliminary median protocol adherence of 56.3%. Adherence began to increase following introduction of the preoperative telephone call (Fig. 1A) and demonstrated special cause with introduction of the revised bathing instructions (Fig. 1B) and S. aureus result telephone call (Fig. 1C). Adherence ultimately reached 87.9% within 6 months of implementation and was sustained for 18 months. Overall adherence for the 24-month period was 80.6%.

FIG. 1.
FIG. 1.

Overall protocol adherence rate. Diamonds represent percentage of adherent procedures per 2-week period; the horizontal axis is labeled approximately monthly. Thick black line represents median percentage of adherence; dotted gray line represents goal percentage of adherence. Letters denote timing of protocol modifications. A = preoperative reminder telephone call; B = revised patient education and instructions; C = S. aureus result reminder telephone call.

Occurrence of SSIs

Preimplementation, the mean age of patients was slightly older; sex and race did not differ. Types of procedures performed differed only for vascular procedures. Four of the 6 surgeons had a different proportion of eligible procedures performed (Table 2). The proportion of shunt procedures resulting in an SSI decreased in the postimplementation period, and 1 provider had a lower SSI rate (Table 3). The SSI rate prior to protocol implementation was 2.9 per 100 procedures. Following protocol implementation, the rate decreased to 0.62 infections per 100 procedures (Fig. 2) (Pearson chi-square 11.5; p = 0.003), with an approximate 79% reduction in SSI risk (risk ratio 0.21, 95% CI 0.08–0.56; p = 0.001) (Table 4).

TABLE 2.

Cohort characteristics

VariablePreimplementationPostimplementationp Value
Mean age in yrs (range)9.4 (0–35.3)8.4 (0–31.6)0.01
Female sex262 (42.6)391 (48.8)0.21
Race0.63
  White502 (81.6)652 (81.4)
  Black or African American56 (9.1)68 (8.5)
  Other*57 (9.3)81 (10.1)
Procedure type
  Craniotomy281 (45.7)349 (43.6)0.67
  Implant117 (19.0)101 (12.6)0.10
  Spine97 (15.8)171 (21.4)0.13
  Shunt74 (12.0)68 (8.5)0.27
  Vascular0 (0)23 (2.9)<0.01
  Other46 (7.48)89 (11.1)0.17
Surgeon
  A64 (10.4)9 (1.1)<0.01
  B295 (48.0)297 (37.1)0.03
  C3 (0.5)0 (0)0.54
  D239 (38.9)269 (33.6)0.28
  E10 (1.6)137 (17.1)<0.01
  F4 (0.7)89 (11.11)<0.01

Values are number of patients (%) or mean (range).

Other races include Asian, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, unknown, and other.

TABLE 3.

SSIs by procedure type and provider

VariablePreimplementationPostimplementationp Value*
Procedure typeNo.SSI (%)No.SSI (%)
  Craniotomy2814 (1.4)3491 (0.3)0.35
  Implant1176 (5.1)1012 (2.0)0.16
  Spine975 (5.2)1712 (1.17)0.07
  Shunt743 (4.1)680 (0)0.04
  Vascular00 (0)230 (0)
  Other460 (0)890 (0)
Surgeon
  A641 (1.6)90 (0)0.20
  B2958 (2.7)2972 (0.67)0.22
  C30 (0)00 (0)
  D2399 (3.8)2692 (0.7)0.10
  E101 (10)1371 (0.73)<0.01
  F40 (0)890 (0)

The p values were calculated using the percentage of procedures that resulted in an SSI.

FIG. 2.
FIG. 2.

The SSI rate per 100 eligible procedures. The dotted line denotes the SSI rate prior to protocol implementation, and the solid line denotes the SSI rate following protocol initiation in January 2014.

TABLE 4.

SSI risk ratio

VariablePreimplementationPostimplementation
No. of procedures597796
No. of infections185
Infection rate, %2.90.62
Risk ratio (95% CI)0.21 (0.08–0.56); p < 0.01

Discussion

The prevention of SSIs in pediatric and adult settings has focused mainly on the intraoperative phase of care. Although effective at reducing SSI rates in many settings, these measures alone have not shown consistent control, nor elimination of SSIs.29,30,52,57 We had an a priori belief that to achieve further reduction, and possibly elimination, of SSIs, attention must be paid to the entire surgical care continuum, namely the pre-, intra-, and postoperative phases of care. Others have shown that a multidisciplinary approach to SSI prevention can reduce rates in adult colorectal and pediatric orthopedic contexts.2,21,28 Based on Centers for Disease Control and Prevention guidance,39 we developed and implemented a standardized preoperative protocol for patients undergoing elective surgery. Subsequently, our SSI rate decreased significantly.

Protocol Composition

Our choice of protocol components was driven by high-quality, rigorous evidence when available. Because such evidence is limited for prevention of pediatric neurosurgical SSIs, the relevant pediatric literature was used with adult literature from neurosurgical and other surgical specialty areas (Table 1). We were careful to choose only those measures we thought would be most appropriate for pediatric populations.

Preoperative bathing that includes multiple CHG cleansings has been shown to affect SSI rates positively.15,18,26 When subjected to meta-analysis, benefit for cleansing with CHG when compared with other cleansing was not observed, although study variability and quality probably affected the analysis.14 CHG cleansing has become a standard preoperative practice across many surgical specialties, in part due to a belief that preoperative bathing reduces skin bacterial load and therefore protects against SSIs.17,24,25,45,60 Our group shared this belief, and thus we included CHG cleansing in our protocol.

Patient/Family Adherence

Our most common failure was patients failing to complete preoperative skin cleansing. Our reminder interventions helped increase family adherence to bathing and probably influenced overall protocol adherence. Reminders such as telephone calls and text messaging have improved adherence to care protocols among patients with chronic illness19 and most recently among adults specifically for preoperative bathing.16 When asked to describe barriers to bathing, most families reported difficulty with the morning bath (given long travel distances), young or developmentally delayed patients, and early report times (not shown). It is unclear whether a single bathing the night before surgery is sufficient to affect SSI prevention. Further study is necessary to determine how many baths and with what agents are the minimal effective combination to maximize SSI prevention.

Prevention of SSIs

Pre- and postimplementation cohorts were similar in most characteristics examined. Where they differed is unlikely to have significantly influenced our SSI rate. Patients in the postimplementation cohort were younger, which would have increased their SSI risk.54 Vascular procedures were performed in the postintervention period only, but none resulted in an SSI (not shown). Of the 6 providers, 4 had a different proportion of eligible procedures performed. This was due to personnel turnover, with Surgeons A and C leaving and Surgeons E and F joining the group. The difference in SSI rate observed for Surgeon E is probably a function of a > 10-fold increase in case load, while having 1 SSI in each period. We do not believe that the decrease in overall SSI rate is due to the change in personnel, because when the same calculations were performed for Surgeons B and D, who performed the majority of procedures in both periods, a significant decrease in rate was observed (not shown).

During the pre- and postintervention periods, no systematic changes were made to intra- or postoperative practices. Of the 6 neurosurgical providers who were active during the 2 periods, many followed published evidence derived from a variety of sources. The addition of new surgeons to the group did not change the practice of the existing practitioners, and no one set of practices was shared by all surgeons. Adherence to the existing perioperative bundle was measured for antibiotic timing, hyperoxygenation, and normothermia, and did not change significantly (not shown). We therefore concluded that standardizing preoperative care affected the SSI rate. However, as a quality improvement initiative, we were unable to infer causality directly.

Previously published studies of protocols have shown SSI rate reduction for specific procedures, such as ventricular shunts or spinal fusions.2,21,30 We purposefully implemented this protocol for all scheduled neurosurgical procedures to test whether an effect on the SSI rate would apply beyond procedures for which there is evidence of efficacy. Our results, along with published studies, suggest that preoperative standardization may improve SSI rates in multiple—possibly all—surgical procedure types. Broad standardization of patient preparation prior to surgery may lead to significant reduction in all SSIs, which recently have been found to be the most common health care–associated infections in the US.38

Limitations of the Study

As in any quality improvement project, context probably played a significant role in our success.27 Our institution has a strong emphasis on safety culture, and quality transformation is embedded in its framework.6 Additionally, we had strong leadership support from the neurosurgeon group, perioperative staff, and the institution's infection control program, all of which probably influenced our success.48

Our interpretation of project results is subject to limitations that are typical of quality improvement efforts. We were unable to conclude directly that preoperative protocol implementation caused a reduction in SSI rates. Adherence data were available for 85% of eligible procedures, and we were unable to determine if something different done for the remaining 15% affected our overall rates. This is unlikely because we found similar results when we compared pre- and postimplementation data using only patients for whom adherence data were available (data not shown).

Our results were potentially confounded by other SSI prevention efforts in our institution, among orthopedic spine and cardiothoracic patients. A meaningful effect on neurosurgical patients is unlikely because crossover of perioperative staff between the 3 specialties seldom occurs. Our adherence data may be confounded by the Hawthorne effect, where the measurement of activity increases the likelihood of activity completion.9 We do not believe that this effect had a major influence on our process, because it generally dissipates over time,3 and our reliability was sustained for > 12 months.

Furthermore, family adherence data are subject to social desirability (e.g., the patient telling the provider what he thinks the provider wants to hear) and recall bias.42 Recall bias is unlikely because families were recalling actions they had taken the night before and the morning of the interview. To avoid social desirability bias, preoperative staff elicited adherence nonthreateningly, such as asking the patient, “Were you able to complete the bathing regimen?” Although we cannot rule out social desirability bias, we do know that many families were willing to tell us when they were not adherent.

Our project was not designed to determine if any components of the protocol provide greater protection than others. Adult studies have shown SSI reduction using a care protocol but could not demonstrate one component that rises above the rest.57 Similarly, a recent publication by the Hydrocephalus Clinical Research Network found a significant association of antibiotic-impregnated catheter with fewer shunt infections, but the addition of antibiotic-impregnated catheters to a prevention bundle failed to decrease infection rates.29 Our project was based on the belief that the standardization of processes with high reliability leads to safer care.37,41 It is possible that the standardized approach played a significant role in the outcome improvement, perhaps to an equal or greater extent than the bundle components themselves. Finally, as a report of a single center's experience, and by excluding unplanned and urgent cases, our results may have limited generalizability.

Conclusions

We developed a reliable SSI prevention system in the preoperative phase of the surgical continuum. Standardization of the preoperative phase of care in the context of partial standardization of intra- and postoperative phases reduced SSI rates. Attention to the preoperative in addition to the intraoperative and postoperative phases of care may lead to a reduction in SSI rates.

Acknowledgments

We thank Charles B. Stevenson, MD; Sudhakar Vadivelu, DO; Timothy Vogel, MD; Karin Bierbrauer, MD; Marc Kirsch; Patti Mercurio; and our partners in the Divisions of Information Services and Patient Services for their diligence and participation in this project. J.K.S. was supported in part for this work by an internal institutional grant that covered partial salary time for J.K.S., Brieanne Sheehan, and Stephanie Brunswick. Use of the REDCap database was funded by a Center for Clinical and Translational Science and Training grant (1UL1TR001425-01).

Appendix Preoperative SSI Prevention Team Members

Lesa Anderson, RN, BSN; Tricia Breeden, MA; Stephanie Brunswick, BS; Theresa Cox, RN, BSN; Amanda Eifert, MA; Veronika E. Elsaesser, RN, BSN, BS, CPN; Paul Henkel, MBA; Michelle Hils, MSN, CNL, RN, CPN; John Holcomb; Colleen McQuaide, BSBA; Amy Myhaver, RN; Jessi Poteet, BS; Jeanie Ransdell, BSN, RN, CPN; Cathy Seliga, BSN, RN; and Brieanne Sheehan, MGS, CPM.

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    Hayashi T, Shirane R, Yokosawa M, Kimiwada T, Tominaga T: Efficacy of intraoperative irrigation with saline for preventing shunt infection. J Neurosurg Pediatr 6:273276, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Institute for Healthcare Improvement: How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty. Cambridge, MA, Institute for Healthcare Improvement, 2012

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Kaiser AB, Kernodle DS, Barg NL, Petracek MR: Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers. Ann Thorac Surg 45:3538, 1988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Kapadia BH, Jauregui JJ, Murray DP, Mont MA: Does preadmission cutaneous chlorhexidine preparation reduce surgical site infections after total hip arthroplasty?. Clin Orthop Relat Res 474:15831588, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Kaplan HC, Brady PW, Dritz MC, Hooper DK, Linam WM, Froehle CM, et al.: The influence of context on quality improvement success in health care: a systematic review of the literature. Milbank Q 88:500559, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Keenan JE, Speicher PJ, Thacker JK, Walter M, Kuchibhatla M, Mantyh CR: The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. JAMA Surg 149:10451052, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Kestle JR, Holubkov R, Douglas Cochrane D, Kulkarni AV, Limbrick DD Jr, Luerssen TG, et al.: A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr 17:391396, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Kestle JR, Riva-Cambrin J, Wellons JC III, Kulkarni AV, Whitehead WE, Walker ML, et al.: A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr 8:2229, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, et al.: Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am 92:18201826, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock DA, et al.: Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 122:160166, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Kluytmans JA, Mouton JW, Ijzerman EP, Vandenbroucke-Grauls CM, Maat AW, Wagenvoort JH, et al.: Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis 171:216219, 1995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Kurz A, Sessler DI, Lenhardt R: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 334:12091215, 1996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, Jossey-Bass, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Lepänluoma M, Takala R, Kotkansalo A, Rahi M, Ikonen TS: Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scand J Surg 103:6672, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Luria JW, Muething SE, Schoettker PJ, Kotagal UR: Reliability science and patient safety. Pediatr Clin North Am 53:11211133, 2006

  • 38

    Magill SS, Hellinger W, Cohen J, Kay R, Bailey C, Boland B, et al.: Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida. Infect Control Hosp Epidemiol 33:283291, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR: Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 20:250280, 1999

  • 40

    Melling AC, Ali B, Scott EM, Leaper DJ: Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 358:876880, 2001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Nolan T, Resar R, Haraden C, Griffin FA: Improving the Reliability of Health Care. Boston, Institute for Healthcare Improvement, 2004

  • 42

    Osterberg L, Blaschke T: Adherence to medication. N Engl J Med 353:487497, 2005

  • 43

    Paulson DS: Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash. Am J Infect Control 21:205209, 1993

  • 44

    Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF: Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg 208:981988, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Popovich KJ, Lyles R, Hayes R, Hota B, Trick W, Weinstein RA, et al.: Relationship between chlorhexidine gluconate skin concentration and microbial density on the skin of critically ill patients bathed daily with chlorhexidine gluconate. Infect Control Hosp Epidemiol 33:889896, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Provost LP, Murray SK: The Health Care Data Guide: Learning from Data for Improvement. San Francisco, Jossey-Bass, 2011

  • 47

    Rao N, Cannella BA, Crossett LS, Yates AJ Jr, McGough RL III, Hamilton CW: Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty 26:15011507, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Resar R, Griffin FA, Haraden C, Nolan TW: Using Care Bundles to Improve Health Care Quality. Cambridge, MA, Institute for Healthcare Improvement, 2012

  • 49

    Richards BR, Emara KM: Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis: revisited. Spine (Phila Pa 1976) 26:19901996, 2001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Ryckman FC, Schoettker PJ, Hays KR, Connelly BL, Blacklidge RL, Bedinghaus CA, et al.: Reducing surgical site infections at a pediatric academic medical center. Jt Comm J Qual Patient Saf 35:192198, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Schroeder HK, Nunes JC, Madeira L, Moritz JL, Walz R, Linhares MN: Postsurgical infection after myelomeningocele repair: a multivariate analysis of 60 consecutive cases. Clin Neurol Neurosurg 114:981985, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Schweizer ML, Chiang HY, Septimus E, Moody J, Braun B, Hafner J, et al.: Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA 313:21622171, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53

    Scott RD II: The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. (http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf) [Accessed November 22, 2016]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54

    Simon TD, Butler J, Whitlock KB, Browd SR, Holubkov R, Kestle JR, et al.: Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study.. J Pediatr 164:14621468, 1468.e11468.e2, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Sneh-Arbib O, Shiferstein A, Dagan N, Fein S, Telem L, Muchtar E, et al.: Surgical site infections following craniotomy focusing on possible post-operative acquisition of infection: prospective cohort study. Eur J Clin Microbiol Infect Dis 32:15111516, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56

    Spader HS, Hertzler DA, Kestle JR, Riva-Cambrin J: Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants. J Neurosurg Pediatr 15:156160, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57

    Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM: Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 303:24792485, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58

    Tuli S, Tuli J, Drake J, Spears J: Predictors of death in pediatric patients requiring cerebrospinal fluid shunts. J Neurosurg 100:5 Suppl Pediatrics 442446, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59

    Valentini LG, Casali C, Chatenoud L, Chiaffarino F, Uberti-Foppa C, Broggi G: Surgical site infections after elective neurosurgery: a survey of 1747 patients. Neurosurgery 62:8896, 2008

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    Vitale MG, Riedel MD, Glotzbecker MP, Matsumoto H, Roye DP, Akbarnia BA, et al.: Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop 33:471478, 2013

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    Yeung LC, Cunningham ML, Allpress AL, Gruss JS, Ellenbogen RG, Zerr DM: Surgical site infections after pediatric intracranial surgery for craniofacial malformations: frequency and risk factors. Neurosurgery 56:733739, 2005

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Disclosures

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

Conception and design: Schaffzin, Connelly, Mangano. Acquisition of data: Schaffzin, Simon. Analysis and interpretation of data: Schaffzin, Simon, Mangano. Drafting the article: Schaffzin. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Schaffzin. Statistical analysis: Simon. Study supervision: Connelly, Mangano.

Supplemental Information

Previous Presentations

Preliminary data were presented at the Society for Healthcare Epidemiology of America Spring 2015 Conference, Orlando, FL, May 14–17, 2015.

  • Collapse
  • Expand
  • Overall protocol adherence rate. Diamonds represent percentage of adherent procedures per 2-week period; the horizontal axis is labeled approximately monthly. Thick black line represents median percentage of adherence; dotted gray line represents goal percentage of adherence. Letters denote timing of protocol modifications. A = preoperative reminder telephone call; B = revised patient education and instructions; C = S. aureus result reminder telephone call.

  • The SSI rate per 100 eligible procedures. The dotted line denotes the SSI rate prior to protocol implementation, and the solid line denotes the SSI rate following protocol initiation in January 2014.

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  • 23

    Hayashi T, Shirane R, Yokosawa M, Kimiwada T, Tominaga T: Efficacy of intraoperative irrigation with saline for preventing shunt infection. J Neurosurg Pediatr 6:273276, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Institute for Healthcare Improvement: How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty. Cambridge, MA, Institute for Healthcare Improvement, 2012

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Kaiser AB, Kernodle DS, Barg NL, Petracek MR: Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers. Ann Thorac Surg 45:3538, 1988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Kapadia BH, Jauregui JJ, Murray DP, Mont MA: Does preadmission cutaneous chlorhexidine preparation reduce surgical site infections after total hip arthroplasty?. Clin Orthop Relat Res 474:15831588, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Kaplan HC, Brady PW, Dritz MC, Hooper DK, Linam WM, Froehle CM, et al.: The influence of context on quality improvement success in health care: a systematic review of the literature. Milbank Q 88:500559, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Keenan JE, Speicher PJ, Thacker JK, Walter M, Kuchibhatla M, Mantyh CR: The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. JAMA Surg 149:10451052, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Kestle JR, Holubkov R, Douglas Cochrane D, Kulkarni AV, Limbrick DD Jr, Luerssen TG, et al.: A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr 17:391396, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Kestle JR, Riva-Cambrin J, Wellons JC III, Kulkarni AV, Whitehead WE, Walker ML, et al.: A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr 8:2229, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, et al.: Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am 92:18201826, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock DA, et al.: Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 122:160166, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Kluytmans JA, Mouton JW, Ijzerman EP, Vandenbroucke-Grauls CM, Maat AW, Wagenvoort JH, et al.: Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis 171:216219, 1995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Kurz A, Sessler DI, Lenhardt R: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 334:12091215, 1996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, Jossey-Bass, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Lepänluoma M, Takala R, Kotkansalo A, Rahi M, Ikonen TS: Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scand J Surg 103:6672, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Luria JW, Muething SE, Schoettker PJ, Kotagal UR: Reliability science and patient safety. Pediatr Clin North Am 53:11211133, 2006

  • 38

    Magill SS, Hellinger W, Cohen J, Kay R, Bailey C, Boland B, et al.: Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida. Infect Control Hosp Epidemiol 33:283291, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR: Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 20:250280, 1999

  • 40

    Melling AC, Ali B, Scott EM, Leaper DJ: Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 358:876880, 2001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Nolan T, Resar R, Haraden C, Griffin FA: Improving the Reliability of Health Care. Boston, Institute for Healthcare Improvement, 2004

  • 42

    Osterberg L, Blaschke T: Adherence to medication. N Engl J Med 353:487497, 2005

  • 43

    Paulson DS: Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash. Am J Infect Control 21:205209, 1993

  • 44

    Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF: Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg 208:981988, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Popovich KJ, Lyles R, Hayes R, Hota B, Trick W, Weinstein RA, et al.: Relationship between chlorhexidine gluconate skin concentration and microbial density on the skin of critically ill patients bathed daily with chlorhexidine gluconate. Infect Control Hosp Epidemiol 33:889896, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Provost LP, Murray SK: The Health Care Data Guide: Learning from Data for Improvement. San Francisco, Jossey-Bass, 2011

  • 47

    Rao N, Cannella BA, Crossett LS, Yates AJ Jr, McGough RL III, Hamilton CW: Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty 26:15011507, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Resar R, Griffin FA, Haraden C, Nolan TW: Using Care Bundles to Improve Health Care Quality. Cambridge, MA, Institute for Healthcare Improvement, 2012

  • 49

    Richards BR, Emara KM: Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis: revisited. Spine (Phila Pa 1976) 26:19901996, 2001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Ryckman FC, Schoettker PJ, Hays KR, Connelly BL, Blacklidge RL, Bedinghaus CA, et al.: Reducing surgical site infections at a pediatric academic medical center. Jt Comm J Qual Patient Saf 35:192198, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Schroeder HK, Nunes JC, Madeira L, Moritz JL, Walz R, Linhares MN: Postsurgical infection after myelomeningocele repair: a multivariate analysis of 60 consecutive cases. Clin Neurol Neurosurg 114:981985, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Schweizer ML, Chiang HY, Septimus E, Moody J, Braun B, Hafner J, et al.: Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA 313:21622171, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53

    Scott RD II: The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. (http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf) [Accessed November 22, 2016]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54

    Simon TD, Butler J, Whitlock KB, Browd SR, Holubkov R, Kestle JR, et al.: Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study.. J Pediatr 164:14621468, 1468.e11468.e2, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Sneh-Arbib O, Shiferstein A, Dagan N, Fein S, Telem L, Muchtar E, et al.: Surgical site infections following craniotomy focusing on possible post-operative acquisition of infection: prospective cohort study. Eur J Clin Microbiol Infect Dis 32:15111516, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56

    Spader HS, Hertzler DA, Kestle JR, Riva-Cambrin J: Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants. J Neurosurg Pediatr 15:156160, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57

    Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM: Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 303:24792485, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58

    Tuli S, Tuli J, Drake J, Spears J: Predictors of death in pediatric patients requiring cerebrospinal fluid shunts. J Neurosurg 100:5 Suppl Pediatrics 442446, 2004

    • PubMed
    • Search Google Scholar
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  • 59

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