Development and Application of Neurosurgery Specific Checklist by Multidisciplinary Infection Prevention Team Leads to Significant Class I Surgical Site Infection (SSI) Rate Reduction

Background: Class I SSIs surveillance trending data demonstrated an increased rate for Neurosurgery (NSG).  Analyses showed no association with pathogen, procedure, or surgeon. A multidisciplinary service specific team to address practices was initiated.

Objective: To identify practices contributing to increase in SSI rates and to implement appropriate interventions including the development of an NSG specific SSI prevention checklist.

Methods: Led by the NSG Chairman, an Infection Prevention (IP) team staffed by personnel from NSG, Operating Room (OR), Anesthesiology (ANE), Nursing, Infection Control, Administration, and Pharmacy carried out biweekly root cause analyses of events and processes associated with identified NSG SSIs. Data collected included procedure and duration, OR staff, SCIP measures, NHSN risk factors, pre-operative chlorhexidine gluconate (CHG) showering, body mass index, co-morbidities, devices, length of stay, discharge care, re-operations/admissions, complications, and microorganisms. IP observed OR and unit practices and provided feedback.  Identified best practices were incorporated into a checklist.

Results: IP developed and implemented an evidence-based checklist including the SCIP measures as they apply to NSG. Prophylaxis with Kefzol was recommended even if vancomycin was given and stopped at 24 hours. Pre-operative CHG showering was monitored. Vendor practice was monitored through sign-in, mandatory education, and observation. IP audited hand hygiene and surgical practices and maintenance of sterile fields, instruments, skin disinfection, and surgical scrub. Based on actual observations, IP recommended a new OR policy to limit human traffic, remove clutter and maintain closed carts. Other interventions included enhanced education presentations to all staff, feedback of device-related and SSI data. NSG staff was asked to report infections to IP and to classify wounds.
Following implementation of these practices via the checklist, there was a documented 88.7% reduction in Class I SSIs (p=0.0001).  In addition, the continuing process of weekly NSG SSI reports and OR monitoring by nurses helped to assure compliance. The NSG team was screened for Staphylococcus aureus. No MRSA was found; 4 persons had MSSA and underwent decolonization. Routine MRSA/MSSA screening/decolonization for patients was initiated.

Conclusions: Measures for NSG SSI prevention are multi-factorial. Deeming every SSI an adverse event trigger can lead to improved outcomes. Observational studies, education, and a multidisciplinary IP effort enhances awareness and results in improved outcomes. Incorporating best practices into a checklist provides consistency in practice. Administrative and physician leadership support of improvement activities are key to success.