Using a Data-Driven Improvement Methodology to Decrease Surgical Site Infections in a Community Neurosurgery Practice: Optimizing Preoperative Screening and Perioperative Antibiotics

Abstract

Objective: We used a data-driven methodology to decrease the departmental surgical site infection rate to a goal of 1%.

Methods: A prospective interventional study with historical controls comparing preimplementation/intervention (unknown methicillin-sensitive Staphylococcus aureus [MSSA]/methicillin-resistant Staphylococcus aureus [MRSA] status and standard weight and drug allergy-based preoperative antibiotics) with postimplementation/intervention (optimized preoperative chlorhexidine showers, MSSA/MRSA screening, MSSA/MRSA decolonization, and optimized preoperative antibiotic order set implementation). The American College of Surgeons National Surgical Quality Improvement Program was used for case surveillance. The primary outcome was the presence of a surgical site infection with a secondary outcome of cost(s) of implementation.

Results: A total of 317 National Surgical Quality Improvement Program abstracted neurosurgical cases were analyzed, 163 cases before implementation and 154 cases after implementation. There were no significant differences between the preimplementation and postimplementation cohorts regarding patient demographics and baseline comorbidities, with the exceptions of inpatient and functional status (P < 0.001). The most common procedures were lumbar decompression (31%), lumbar discectomy (27%), and anterior cervical discectomy and fusion (10.4%). After implementation, 30 patients were MSSA positive (20%) and 4 MRSA positive (2.6%). Thirty patients received preoperative intranasal mupirocin decolonization (88%), and 4 patients received adjusted preoperative antibiotics (12%). After protocol implementation, the surgical site infection rate decreased from 6.7% (odds ratio, 2.82) to 0.96% (odds ratio, 0.91). The cost of implementation was $27,179, or $58 per patient.

Conclusions: The findings highlight the importance of systematically investigating areas of gap in existing clinical practice and quality improvement projects to increase patient safety and enhance the value of care delivered to neurosurgical patients.

Keywords: Antibiotic dosing; Antibiotic selection; Cost of care; Methicillin-resistant Staphylococcus aureus; Methicillin-sensitive Staphylococcus aureus; Preoperative screening; Surgical site infection.