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(146) A Benchmark Approach to Reducing Surgical Site Infections

John Polikandriotis, PhD, MBA; and Valerie Maxam-Moore, MN, RN


Incisional surgical site infections (SSIs) have been reported after 2% to 6% of all spinal surgeries and 0.22% for minimally invasive spine surgeries in published studies. During the second and third quarters of 2009, one of our facilities completed 784 minimally invasive spine surgeries, and the rate of SSIs at this facility was 0.76%. Our other facility in the same time period completed 1,590 minimally invasive spine surgeries and had a 0.06% SSI rate. Since both centers perform the same types of procedures and have similar patient demographics, this discrepancy in SSI rate raised concern among the nursing and medical professionals. The purpose of this initiative was to reduce the rate of infection of facility one through comparative benchmarking with facility two. A multidisciplinary team was formed, and a focused review was performed to evaluate infection control measures at both surgical centers. A presentation of the findings, infection control practices, and variations in care between the two centers was presented to the center staff. Corrective measures, such as standardized dressing change protocols, were established and implemented. The SSI rate at facility one declined from 0.76% to 0.00% in the following quarter's follow-up study, during which 329 procedures were performed. The findings of this study have shown our staff the value of regular internal benchmarking between our surgery centers for rapid identification and correction of concerns related to quality care.

Primary Author:

John Polikandriotis

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