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Spine Deform. 2019 Jan;7(1):33-39. doi: 10.1016/j.jspd.2018.06.010.

Implementing a Multidisciplinary Clinical Pathway Can Reduce the Deep Surgical Site Infection Rate After Posterior Spinal Fusion in High-Risk Patients.

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Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA. Electronic address:
Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA.



Retrospective comparative study.


The purpose of this study is to measure SSI outcomes before and after implementation of our center's multidisciplinary clinical pathway protocol for high-risk spinal surgery.


Surgical site infections (SSIs) after spinal fusion harm patients and are associated with significant health care costs. Given the high rate of SSI in neuromuscular populations, there is a rationale to develop infection prevention strategies.


An institutional clinical pathway was created in 2012 and based on nationally published Best Practice Guidelines as well as hospital practices with a goal of reducing the rate of deep SSI in high-risk patients. Patient and procedure characteristics were compared prior to (2008-2011) and after (2012-2016) implementation of the pathway. Logistic regression using penalized maximum likelihood was used to assess differences in rate of infection before and after implementation.


Cohorts of 132 and 115 high-risk patients were analyzed before and after pathway implementation. Rate of deep infections decreased from 8% to 1% of patients (p = .005). Preoperative antibiotics were dosed within 1 hour in 90% of the postpathway cohort. Redosing was successful in 94% of patients for first redose and 79% for second redose. Betadine irrigation was used in 76% of cases and vancomycin administered in 86%. Multivariable analysis determined that instances of compliant antibiotics dosing had 63% lower odds of infection compared with instances of noncompliance (p = .04).


Implementation of a multidisciplinary pathway aimed to reduce infection in patients at high risk for SSI after spinal fusion led to a significant reduction in deep SSI rate. It is impossible to attribute the drop in the deep SSI rate to any one factor. Our results demonstrate that adherence to a protocol using multiple strategies to reduce infection results in a lower SSI rate, lower care costs, and improved patient-related outcomes.


Level III.


Infection protocol; Neuromuscular scoliosis; Scoliosis; Surgical site infection

[Indexed for MEDLINE]

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