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Building Consensus Development of a Best Practice Guideline (BPG) In Pediatric Spine SSI Prevention

Saturday, October 20, 2012: 1:21 PM
Melrose (Hilton Riverside)
Michael G. Vitale, MD, MPH, FAAP1, Matthew D. Riedel, BA1, Lisa Saiman, MD, MPH2, Hiroko Matsumoto, MA1, Michael Glotzbecker, MD3, John Emans, M.D.4, Mark A. Erickson, MD5, John Flynn, MD, FAAP6, Behrooz A. Akbarnia, M.D.7, Richard C. E. Anderson, MD8, Douglas Brockmeyer, MD9, Lawrence G. Lenke, MD10, Scott J. Luhmann, M.D.11, Stephen Lewis, MD12, Peter O. Newton13, B. Stephens Richards III, MD14, Daniel Sucato, MD, MS14, Suken A. Shah, MD15, David L. Skaggs, MD16, John T. Smith, MD17, PD Sponseller18, Reinhard Zeller, MD19, Ann-Christine Nyquist, MD, MSPH20, Lisa Mcleod, MD21 and David P. Roye Jr., MD1, (1)Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, (2)Department of Infection Prevention and Control, Columbia University Medical Center, New York, NY, (3)Department of Orthopaedics, Children's Hospital Boston, Boston, MA, (4)Orthopedic Surgery, Children's Hospital Boston, Boston, MA, (5)Orthopaedics, Children's Hospital Colorado, Aurora, CO, (6)Department of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, (7)San Diego Center for Spinal Disorders, La Jolla, CA, (8)Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, Children's Hospital of New York-Presbyterian, New York, NY, (9)Department of Neurological Surgery, Primary Children's Medical Center, Salt Lake City, UT, (10)Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, (11)Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, (12)Department of Orthopaedic Surgery, Toronto Western Hospital, Toronto, ON, Canada, (13)Orthopedics, Radys Children Hospital, San Diego, CA, (14)Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, TX, (15)Pedatric Orthopedics and Scoliosis, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, (16)Orthopaedic Surgery, Childrens Hospital of Los Angeles, Los Angeles, CA, (17)The University of Utah School of Medicine, (18)Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, (19)Department of Orthopaedic Surgery, Hospital for Sick Children, Toronto, ON, Canada, (20)Section of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, (21)Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA

Purpose

Surgical site infection (SSI) following pediatric scoliosis instrumentation is a recognized complication. SSIs impose tremendous burden on the health of patients and significant cost to the healthcare system. A practice guideline can decrease practice variability and improve outcomes in this area. The purpose of this study is to utilize a systematic review of the literature to drive a consensus based process and develop a set of “Best Practice” guidelines (BPG) in this area.

Methods

SSI prevention techniques were identified and grades of evidence were determined through systematic literature review. A survey was then administered to 20 pediatric spine surgeons, assessing which techniques are used and willingness to adopt techniques in high risk (non-idiopathic) patients. Initial results were compiled and compared to the identified literature. This data was presented and discussed by all participants. After discussion was completed, Audience Response surveying (ARS) was done in which each participant answered “strongly agree, agree, disagree, or strongly disagree” for inclusion of each intervention in the final BPG. Agreement >80% was considered consensus. Items near consensus (70-79% agreement) were discussed again.  Another round of ARS was done for those items after discussion.

Results

Consensus was reached on 14 SSI prevention interventions. 100% of the participants agreed to support publication of this BPG, implement it for high-risk patients at their respective institutions, and participate in a study validating it. The final consensus-driven BPG includes:

1)      Patients should have a Chlorhexidine skin wash at home the night before surgery. – 91% Consensus

2)      Patients should have pre-operative urine cultures obtained. – 91% Consensus

3)      Patients should receive a pre-operative Patient Education Sheet. – 91% Consensus

4)      Patients should have a pre-operative nutritional assessment. – 96% Consensus

5)      If removing hair, clipping is preferred to shaving. – 100% Consensus

6)      Patients should receive peri-operative IV Cefazolin. – 91% Consensus

7)      Patients should receive peri-operative IV prophylaxis for gram negative bacilli. – 95% Consensus

8)      Adherence to peri-operative antimicrobial regimens should be monitored.– 96% Consensus

9)      OR access should be limited during scoliosis surgery. (whenever possible) – 96% Consensus

10)  UV lights should be used in the OR. – 87% Consensus AGAINST

11)  Patients should have intra-operative wound irrigation. – 100% Consensus

12)  Vancomycin powder should be used in the bone graft and/or the surgical site. – 91% Consensus

13)  Impervious dressings are preferred. (post-operatively) –91% Consensus

14)  Post-operative dressing changes should be minimized prior to discharge to the extent possible. – 91% Consensus

Conclusion

This study combines the practice and knowledge of 20 experienced pediatric spine surgeons as well as summarizes the available evidence to provide a literature and consensus-driven BPG which spine surgeons can implement to reduce SSI rates for high risk patients in their own practices.