Leo Spector, MD – OrthoCarolina, Matthews, NC (Presbyterian Orthopedic Hospital)

Surgical site infections (SSIs) have been identified as one of the most important preventable sources of morbidity and mortality associated w/medical treatment.  Staphylococcus aureus is considered to be the most important pathogen in terms of SSIs. Epidemiologic studies have demonstrated that most cases of SSIs are caused by strains of Staph aureus that are brought into the hospital environment by patients themselves; i.e., most patients who develop Staph aureus SSIs are carriers of the strains causing the infection. On the average, SSI is associated with a two-week increase in hospital stay, double the rate of rehospitalization, and triple the overall cost of treatment.

Between January and November 2010, the overall SSI rate at Presbyterian Orthopedic Hospital for all lumbar spine operations was 0.83% (10/1211); 0.96% (6/622) for lumbar fusion and 0.68% (4/589) for lumbar laminectomy/microdiscectomy. Of the ten SSIs, four were Methicillin-Resistant Staph aureus (MRSA) and three was Methicillin-Sensitive Staph aureus (MSSA). Patients deemed high risk for being MRSA carriers by the surgeon undergo pre-operative nasal screening for MRSA. Those found to be carriers of MRSA are treated with a five day course of intranasal 2% mupirocin ointment (Bactroban; GlaxoSmithKline, Middlesex, United Kingdom), and a shower wash w/4% chorhexadine gluconate (Hibiclens; Molnlycke Health Care, Norcross, Georgia). Patients are then rescreened on the day of surgery and treated with the appropriate antibiotic based on the success of the eradication of the MRSA.

Between January and November 2010, only 13% (157/1211) patients undergoing lumbar spine surgery were screened pre-operatively in the same time period.  In an effort to reduce SSIs, Dr. Spector  and his colleagues plan on institutionalizing the pre-operative screening of MRSA.  The goal is to screen 95% of all patients undergoing lumbar spine surgery and continue to monitor the SSI rate at our hospital.

Bi-monthly meetings began on September 3, 2010. Dr. Spector and his team have participated in a webinar with Dr. David Kim and the staff at the New England Baptist hospital on “Institutional Prescreening for Detection and Eradication of Methicillin-Resistant Staphylococcus aureus in Patients Undergoing Elective Orthopaedic Surgery” (JBJS 2010;92:1820-1826). Dr. Spector’s team has educated all clinical hospital employees using online education and a hands-on education walkthrough to engage staff and provide multiple learning opportunities. They have also met with all the spine surgeons and staff. This project is focused on screening patients for MRSA prior to spinal surgery to reduce surgical site infections and includes moving from screening “high-risk” patients to universal screening. The patient screening program began on January 3, 2011. The process has already identified and begun treatment of five MRSA patients.

July 2011 Update

  • The team will be reviewing 1st and 2nd quarter data comparing 2010 and 2011 at the next meeting. (Note: Following the meeting, Dr. Spector conveyed the MRSA infection rate had decreased 80% from year to year.)
  • The next issue to be addressed is the number of patients that received Vancomycin in error due to the labs not returned prior to surgery.
  • In regard to sustainability – the processes are not automated so compliance is variable.
  • Unintended consequences – issues with SCIP measures – timing of perioperative antibiotics.
  • When asked how he plans to continue QI efforts Dr. Spector said, “The focus on QI is what its about. When you see the benefit to the patients, you want to keep going. Participation with the QI department has created a positive environment with administration.”
  • Dr. Spector will be leading the Quality Committee for OrthoCarolina.

NCPIQUE Quality Fellows presentation to NCMS Foundation Board of Trustees on October 21, 2011.