Introduction: Previous studies have demonstrated the efficacy of infection prevention protocols in reducing infection rates. However, there exists a lack of literature on the implementation of infection prevention bundles to reduce SSIs specifically in patients undergoing spine surgery. Furthermore, besides formal infection prevention bundles, the effect of physician awareness interventions on healthcare risks has not been adequately addressed. As such, we investigated the effects of an evolving infection prevention protocol augmented by increased physician awareness on spine surgery infection rates and resultant cost containment.

Methods: Neurological spine surgeons at a single academic institution were informed of spine surgery infection control measures as well as individual, independently adjudicated, spine surgery infection rates and rankings amongst their institutional peers. The groups were divided into those that actively employed recommended infection control measure protocols, and those that did not.

Results: With the implementation of postoperative surgical dressing measures and physician awareness, the postoperative spine surgery infection rate decreased by 45% from 3.8% to 2.1% for collaborative neurosurgeons (Risk Ratio = 0.55; 95% CI, 0.32 – 0.93; p = 0.03), resulting in an estimated annual cost savings of $291,000. This reduction in infection rate was not observed for non-collaborative neurosurgeons, though the overall infection rate amongst all neurosurgeons decreased from 3.3% to 1.5% (Risk Ratio = 0.46; 95% CI, 0.28 – 0.73; p = 0.0013). Thus, it appears as if the infection rate reduction amongst collaborative neurosurgeons was driving the reduction in the overall infection rate amongst all neurosurgeons.

Conclusions: A novel paradigm for spine surgery infection control combined with physician awareness methods resulted in significantly decreased infection rates and associated cost reduction. Thus, information sharing and physician engagement as a supplement to formal infection control measures results in improvements in surgical safety and costs.

Patient Care: In this manuscript, we examine the effects of a novel paradigm for spine surgery infection control combined with physician awareness methods which resulted in in significantly decreased infection rates and an associated cost reduction. By implementing this evolving model, other institutions may be able to improve patient care and outcomes as well.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of infection prevention bundles to reduce surgical site infections specifically in patients undergoing spine surgery, 2) Discuss, in small groups, the potential for cost savings associated with reduced infection rates, 3) Identify an effective methods to utilize physician awareness to augment infection prevention bundles to reduce surgical site infections.

References: 1. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R, et al: Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 362:9-17, 2010 2. Caroom C, Tullar JM, Benton EG, Jr., Jones JR, Chaput CD: Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion. Spine (Phila Pa 1976) 38:1183-1187, 2013 3. Dennis HH, Wei DT, Darren KZ, Shantakumar JT, Kumar N, Lau LL, et al: Is Intraoperative Local Vancomycin Powder the Answer to Surgical Site Infections in Spine Surgery? Spine (Phila Pa 1976), 2016 4. Epstein NE: Preoperative, intraoperative, and postoperative measures to further reduce spinal infections. Surg Neurol Int 2:17, 2011 5. Featherall J, Miller JA, Bennett EE, Lubelski D, Wang H, Khalaf T, et al: Implementation of an Infection Prevention Bundle to Reduce Surgical Site Infections and Cost Following Spine Surgery. JAMA Surg, 2016 6. Ghobrial GM, Cadotte DW, Williams K, Jr., Fehlings MG, Harrop JS: Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review. Neurosurg Focus 39:E11, 2015 7. Hickson GB, Pichert JW, Webb LE, Gabbe SG: A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med 82:1040-1048, 2007 8. Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, Bogaers-Hofman D, de Baere GA, Stuurman A, et al: Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis 35:353-358, 2002 9. Kanayama M, Hashimoto T, Shigenobu K, Oha F, Togawa D: Effective prevention of surgical site infection using a Centers for Disease Control and Prevention guideline-based antimicrobial prophylaxis in lumbar spine surgery. J Neurosurg Spine 6:327-329, 2007 10. Kang BU, Lee SH, Ahn Y, Choi WC, Choi YG: Surgical site infection in spinal surgery: detection and management based on serial C-reactive protein measurements. J Neurosurg Spine 13:158-164, 2010 11. Kang DG, Holekamp TF, Wagner SC, Lehman RA, Jr.: Intrasite vancomycin powder for the prevention of surgical site infection in spine surgery: a systematic literature review. Spine J 15:762-770, 2015 12. 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 474:1583-1588, 2016 13. Klemencsics I, Lazary A, Szoverfi Z, Bozsodi A, Eltes P, Varga PP: Risk factors for surgical site infection in elective routine degenerative lumbar surgeries. Spine J, 2016 14. Kluytmans J, Harbarth S: Methicillin-resistant Staphylococcus aureus decolonization: "yes, we can," but will it help? Infect Control Hosp Epidemiol 30:633-635, 2009 15. Lewkonia P, DiPaola C, Street J: Incidence and risk of delayed surgical site infection following instrumented lumbar spine fusion. J Clin Neurosci 23:76-80, 2016 16. Martin JR, Adogwa O, Brown CR, Kuchibhatla M, Bagley CA, Lad SP, et al: Experience with intrawound vancomycin powder for posterior cervical fusion surgery. J Neurosurg Spine 22:26-33, 2015 17. Martinez W, Hickson GB, Miller BM, Doukas DJ, Buckley JD, Song J, et al: Role-modeling and medical error disclosure: a national survey of trainees. Acad Med 89:482-489, 2014 18. Pichert JW, Hickson G, Moore I: Using Patient Complaints to Promote Patient Safety, in Henriksen K, Battles JB, Keyes MA, Grady ML (eds): Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD), 2008 19. 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 313:2162-2171, 2015 20. Scott R: The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, in. Atlanta, GA: Centers for Disease Control and Prevention, 2009 21. Stammen LA, Stalmeijer RE, Paternotte E, Oudkerk Pool A, Driessen EW, Scheele F, et al: Training Physicians to Provide High-Value, Cost-Conscious Care: A Systematic Review. JAMA 314:2384-2400, 2015 22. Suh BK, Moon SH, Kim TH, Oh JK, Kwon YS, Park JS, et al: Efficacy of Antibiotics Sprayed into Surgical Site for Prevention of the Contamination in the Spinal Surgery. Asian Spine J 9:517-521, 2015 23. Swan JT, Ashton CM, Bui LN, Pham VP, Shirkey BA, Blackshear JE, et al: Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU: A Single-Center, Randomized Controlled Trial. Crit Care Med 44:1822-1832, 2016 24. Thakkar V, Ghobrial GM, Maulucci CM, Singhal S, Prasad SK, Harrop JS, et al: Nasal MRSA colonization: impact on surgical site infection following spine surgery. Clin Neurol Neurosurg 125:94-97, 2014