Reduction of Pediatric Surgical Site Infection (SSI) Using a Standardized Root-Cause Analysis (RCA) Form

Background: Quality improvement programs to reduce SSI, such as the Surgical Care Improvement Project (SCIP), have largely overlooked or excluded pediatric programs.  To reduce SSI following pediatric cardiac, neurosurgery and orthopedic procedures, Ohio will require public reporting of SSI rates starting in 2011.  Eight Ohio Children’s Hospitals have joined the Ohio Solution for Patient Safety to develop and share quality initiatives to reduce pediatric SSI. 

Objective: To identify SSI risk factors, our hospital developed an improved RCA form.  The form contains fields for demographic information, the identified organism, and for pre-operative, intra-operative and post-operative factors that might contribute to SSI risk.  Data includes information on use of clippers, surgical prep, antibiotic timing and redosing, blood loss, oxygenation, glucose, chlorhexidine gluconate bathing, and Staphylococcus aureus screening.

Methods: We retrospectively used the RCA form to investigate a cluster of Propionibacterium acnes (n=6) orthopedic spine SSI that occurred in patients undergoing scoliosis surgery with spinal rod placement. 

Results: Demographic features of patients with SSI were as follows: mean age-15 years; female 83%; operating room A (33%) & B (67%); surgeon A (33%), B (33%), & C (33%); time to infection (mean 101 days; range 8-304 days; median 25-58 days). Pre-operative risk factors: chlorhexidine gluconate bath (no data 83%; not given 17%); S. aureus screening (0%); appropriate surgical prep (100%), correct initial antibiotic timing (100%), no razors (100%); and antibiotic used (cefazolin 67%; clindamycin 33%).  Intra-operative risk factors: highest glucose (121), warming devise used (67%), blood loss (1700 cc); mean procedure time (251 minutes); correct antibiotic redosing by 4 hours (33%; in a patient correctly redosed with clindamycin antibiotic resistance was present).

Conclusions: Without performing a formal case control study, a RCA may be used to rapidly identify risk factors for SSI.  Our analysis of P. Acne SSI in pediatric orthopedic patients identified long procedure time, extensive blood loss, failure to redose antibiotics at 4 hours, and resistance of P. acnes to clindamycin as possible risk factors.  Based on this RCA, we initiated a quality improvement projects directed at standardizing antibiotic choice, dose and time of intra-operative antibiotic redosing.  Across the 3 designated pediatric procedures, the rate of correct intra-operative redosing at our hospital increased from 75% (2009) to 95% (through 9/2010) and the rate of SSI decreased by 53%.